Columtjia  ®niber£fitp 
in  tf)E  Citp  of  ^etD  |9ork 

COLLEGE  OF  PHYSICIANS 
AND  SURGEONS 


Reference  Library 

Given  by 


OX-^K-^K. 


The  Health  Officer 


By 

FRANK  OVERTON,  A.  M.,  M.  D.,  D.  P.  H. 

Sanitary  Supervisor,  New  York  State  Department  of  Health 


and 


WILLARD  J.  DENNO,  A.  B.,  M.  D.,  D.  P.  H. 

Medical  Director  of  the  Standard  Oil  Company 
Formerly  Secretary  New  York  State  Department  of  Health 


ORIGINAL   ILLUSTRATIONS 


PHILADELPHIA   AND  LONDON 

W.     B.    SAUNDERS     COMPANY 

1919 


Copyright,  igig,  bj'  W.  15.  Saunders  Company 


PRINTED    IN    AMERICA 

PRESS    OF 

,    B.    SAUNDERS    COMPANY 

PHILADELPHIA 


PREFACE 

This  book  contains  the  information  which  the  average 
health  officer  must  have  in  order  to  discharge  his  duties.  It 
tells  the  health  officer  what  to  do,  how  to  do  it,  and  why  he 
should  do  it.  It  describes  the  various  activities  in  which  a 
health  officer  engages;  his  relation  to  boards  of  health,  phy- 
sicians, social  agencies,  and  the  public;  his  qualifications  and 
methods  of  work;  the  various  diseases  and  unsanitary  conditions 
with  which  he  deals;  and  the  scientific  principles  on  which  the 
specialty  of  preventive  medicine  is  founded.  It  is  the  result 
of  the  years  of  experience  of  the  authors  in  public  health  work, 
both  in  rural  communities  and  in  New  York  City,  and  as  super- 
visors of  health  officers  under  the  New  York  State  Department 
of  Health.  While  the  book  is  designed  primarily  for  health 
officers,  its  simple  language  and  untechnical  form  will  commend 
it  to  college  students,  public  health  nurses,  members  of  boards 
of  health,  social  workers,  teachers,  and  others  who  are  interested 
in  public  health  work. 

The  Authors. 

May,  1919. 

11 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/healthofficerOOover 


CONTENTS 


CHAPTER  I 

PACE 

Organization  and  Powers  of  a  Health  Department 17 

CHAPTER  II 
The  Health  Officer  Himself 25 

CHAPTER  HI 

The  Local  Board  of  Health 34 

CHAPTER  IV 

The  Public  and  the  Health  Officer .• 45 

CHAPTER  V 

The  Physician  and  the  Health  Officer 50 

CHAPTER  VI 

Rural  Public  Health  Work 56 

CHAPTER  VII 

Records  and  Reports 63 

CHAPTER  VIII 
Standard  Procedures 73 

CHAPTER  IX 

Local  Sanitary  Code 81 

CHAPTER  X 
Vital  Statistics 97 

CHAPTER  XI 

Public  Health  Nursing 112 

CHAPTER  XII 
Publicity  and  Education 119 

CHAPTER  Xin 
Bacteriology 128 

CHAPTER  XIV 
Immunity 140 

13 


14  CONTENTS 

CHAPTER  XV 

PAGE 

The  Public  Health  Laboratory 159 

CHAPTER  X\I 
Epidemiology 168 

CHAPTER  XVn 

The  M.anagemext  of  a  Case  of  Communic.-vble  Disease.  . : 183 

CHAPTER  XVIII 

The  Minor  Communicable  Diseases 196 

CHAPTER  XIX 
Sm.\llpox 202 

CHAPTER  XX 

Diphtheria 212 

CHAPTER  XXI 

Septic  Sore  Throat 225 

CHAPTER  XXII 
Scarlet  Fex'er 229 

CHAPTER  XXIIT 

Acute  Respiratory  Diseases ." 236 

CHAPTER  XXIV 
Infections  of  the  DicESTn-E  Organs 254 

CHAPTER  XXV 
Infections  of  the  Central  Nervous  System 267 

CHAPTER  XX\  I 
Ventjreal  Diseases .' 280 

CHAPTER  XX\TI 

Tuberculosis 290 

CH APTER  XXWIT 
Insect-borne  Diseases 301 

CHAPTER  XXrX 

Miscellaneous  Diseases 306 

CHAPTER  XXX 
Mental  Defects 313 

CHAPTER  XXXI 

Vermin 327 


CONTENTS  15 

CHAPTER  XXXII  pack 

Milk 344 

CHAPTER  XXXIII 

Food  Sanitation 371 

CHAPTER  XXXIV 

Food  Values 384 

CHAPTER  XXXV 
Sanitary  Engineering 399 

CHAPTER  XXXVI 
Nuisances 406 

CHAPTER  XXXVH 
The  Disposal  of  Household  Wastes 422 

CHAPTER  XXXVIII 
Sewage  Disposal 434 

CHAPTER  XXXIX 
Water-supplies 449 

CHAPTER  XL 
Ventilation. 465 

CHAPTER  XLI 

Industrial  Hygiene 477 

CHAPTER  XLII 
Camp  Sanitation 482 

CHAPTER  XLIII 
Child  Hygiene. 488 

CHAPTER  XLIV 
Life  Extension  ... 502 


Index. 507 


THE   HEALTH   OFFICER 


CHAPTER  I 


ORGANIZATION  AND  POWERS  OF  A  HEALTH 
DEPARTMENT 

Departments  of  Health. — The  prevention  of  diseases  has  long 
been  recognized  as  one  of  the  duties  of  a  government.  This 
duty  in  the  United  States  of  America  lies  primarily  with  the 
several  states.  Nearly  every  state  in  the  Union  has  a  depart- 
ment of  health  to  which  various  powers  are  given  for  the  purpose 
of  suppressing  epidemics,  preventing  diseases,  and  promoting 
the  strength  and  vigor  of  the  people. 

United  States  Public  Health  Service. — The  government  of 
the  United  States  maintains  an  efficient  organization,  called  the 
Public  Health  Service,  in  order  to  deal  with  health  problems 
which  are  beyond  the  jurisdiction  or  power  of  the  states.  The 
principal  activities  of  the  national  organization  are  as  follows: 

1.  The  control  of  health  work  on  vessels  entering  the  sea- 
ports of  the  United  States  and  its  colonies. 

2.  Detailed  public  health  work  on  United  States  Govern- 
ment reservations. 

3.  Advising  and  assisting  state  and  local  authorities,  par- 
ticularly in  conditions  which  may  effect  the  health  of  people  in 
adjacent  states,  as  in  the  poliomyelitis  epidemic  of  1916. 

4.  Investigation,  research,  and  standardization.  Examples 
of  these  activities  are  recording  contagious  diseases  throughout 
the  world,  researches  into  the  causes  of  typhus  fever,  and  main- 
taining a  supply  of  antitoxins  of  standard  strength  to  be  used  for 
testing  purposes. 

State  Departments  of  Health. — Experience  has  demonstrated 
that  the  essential  staff  which  is  necessary  for  conducting  pub- 
lic health  work  in  a  state  is  as  follows : 

1.  A  central  staff  of  technical  experts,  administrators,  and 
clerks. 

2.  A  field  staff  to  supervise  the  local  workers  in  the  various 
municipalities. 

3.  Local  health  officers. 

2  17 


18  THE   HEALTH    OFFICER 

The  manner  of  organization  of  the  staff  differs  widely  in  the 
various  states.  The  State  Departments  of  Health  of  Pennsyl- 
vania and  Florida  conduct  all  phases  of  public  health  work,  and 
the  local  municipalities  have  little  or  no  legal  duties  or  responsi- 
bilities. The  State  Departments  of  Health  of  Michigan,  Cali- 
fornia, and  Indiana  are  responsible  for  most  phases  of  local  work, 
but  many  duties  and  responsibilities  are  lodged  with  the  local 
municipalities.  The  original  public  health  laws  of  New  York 
State  placed  the  responsibility  for  public  health  wholly  upon  the 
individual  cities,  villages,  and  townships.  The  local  municipal- 
ities are  still  supreme  in  carrying  out  the  details  of  public  health 
work.  Broad  general  powers  are  also  given  to  the  State  Depart- 
ment of  Health,  although  they  are  not  always  clearly  defined. 
New  York  State  may  be  classed  among  those  states  in  which  the 
responsibihty  for  local  health  work  is  placed  jointly  upon  the 
state  and  the  local  municipalities. 

The  activities  of  the  health  departments  of  some  states  are 
merely  statistical  and  advisory,  and  in  these  states  the  work  of 
the  local  municipalities  is  ineihcient  and  confused. 

A  standard  form  of  organization  is  that  adopted  by  New 
York,  Massachusetts,  Maine,  and  other  states,  and  is  as  follows: 

1.  A  commissioner  of  health  and  his  staff. 

2.  A  public  health  council  to  have  legislative  and  advisory 
powers,  particularly  the  power  to  enact  a  sanitary  code. 

3.  Directors  of  divisions  and  their  staffs.  The  divisions  in- 
clude vital  statistics,  communicable  diseases,  sanitary  engineer- 
ing, laboratory,  child  hygiene,  and  public  health  education. 

4.  Local  health  ofiticers  in  the  various  municipalities. 

The  form  of  the  organization  for  doing  pubhc  health  work  is  of 
less  importance  than  the  personnel  of  the  staff,  and  the  financial 
means  at  the  disposal  of  the  officials;  but  the  appropriations 
themselves  depend  largely  upon  the  personality  and  efficiency 
of  the  members  of  the  staff.  Capable  officials  will  find  ways  of 
doing  efficient  work  regardless  of  the  form  of  the  organization 
under  which  they  work. 

Source  of  Power  of  Health  Departments. — The  powers  of  a 
department  of  health,  or  health  officer,  are  derived  from  acts  of 
the  legislature.  No  act  of  a  department  or  board  of  health  is 
legal  unless  authority  for  it  is  found  in  a  law  passed  by  the  legis- 
lature. The  legislatures  of  the  various  states  have  passed 
general  laws  regarding  health  matters,  and  have  delegated  to 
certain  other  political  bodies  and  to  certain  officers  the  power 
to  make  additional  rules  and  regulations  which  have  the  force  of 
laws  provided  they  are  not  inconsistent  with  higher  laws.  The 
body  of  laws  enacted  by  the  legislature  of  a  state  constitute  the 


ORGANIZATION  AND   POWERS    OF   A   IIKALTII    DEPARTMENT       19 

trunk  of  the  legal  tree  whose  branches  are  the  rules  and  regula- 
tions and  the  modes  of  procedure  of  the  state  and  local  health 
departments. 

Consolidated  Laws. — The  legislative  enactments  of  a  state 
are  collected  and  arranged  in  what  are  called  the  consolidated 
laws,  and  comprise  four  different  codes:  1,  The  penal  code;  2, 
the  code  of  criminal  procedure;  3,  the  code  of  civil  procedure;  4, 
the  great  mass  of  laws  which  correspond  to  the  civil  code,  and 
whose  subdivisions  are  known  by  the  names  of  the  public  health 
law,  the  village  law,  the  town  law,  and  other  descriptive  titles. 
Health  matters  are  frequently  mentioned  in  other  laws  than  in 
the  particular  ones  relating  especially  to  health. 

A  subject  in  a  law  is  usually  located  by  means  of  the  title  of 
the  law,  and  the  number  of  the  article  and  section  in  which  it  is 
found.  For  example,  the  authority  for  the  organization  of  local 
boards  of  health  in  New  York  State  is  found  in  the  Public  Health 
Law,  Article  3,  Sections  21  to  21c  inclusive. 

Court  Decisions. — ^Legislative  enactments  are  called  statutory 
or  written  laws.  In  addition  to  these  laws,  the  decisions  of  the 
courts  are  the  source  of  much  of  the  authority  of  boards  of  health. 
These  decisions  are  founded  on  the  written  laws  and  make  appli- 
cations of  them  to  specific  cases  and  doubtful  conditions.  They 
form  a  part  of  what  is  called  the  unwritten  law  of  a  state.  They 
indicate  many  of  the  details  of  what  a  health  officer  or  depart- 
ment of  health  can  legally  do  under  a  statute  law. 

The  decisions  which  are  most  frequently  quoted  are  those  of 
the  highest  court  of  a  state,  and  are  referred  to  by  means  of  the 
volume  and  page  of  the  report.  For  example,  the  cold  storage 
law  of  New  York  State  was  held  to  be  constitutional,  and  the 
decision  is  recorded  in  volume  160,  p.  591,  of  the  reports  of  the 
New  York  Court  Appeals.  This  is  usually  abbreviated  as  160 
N.  Y.  591. 

Public  Health  Council. — The  legislatures  of  some  of  the  states 
have  established  special  bodies  called  public  health  councils, 
and  have  delegated  to  them  the  power  to  make  rules  and  regula- 
tions which  shall  have  the  force  of  law  in  all  matters  relating  to 
public  health.  The  PubHc  Health  Council  of  New  York  State 
has  drafted  a  sanitary  code  which  applies  to  the  whole  state  out- 
side of  New  York  City.  The  establishment  of  a  public  health 
council  is  an  advanced  step  in  public  health.  It  enables  a  body 
of  experts  to  keep  a  sanitary  code  up  to  date  and  to  take  advan- 
tage of  new  discoveries  as  soon  as  they  are  announced.  It  also 
makes  possible  a  uniform  method  of  procedure  throughout  the 
state. 

Local  Ordinances. — The  legislatures  of  many  states  have  also 


20  THE  HEALTH   OFFICER 

delegated  to  local  departments  of  health  the  power  to  make  health 
ordinances,  provided  they  are  not  inconsistent  with  the  laws 
or  sanitary  code  of  the  state.  The  local  codes  usually  deal  with 
matters  of  minor  detail,  such  as  the  suppression  of  nuisances, 
while  the  state  codes  and  laws  deal  with  matters  of  greater  im- 
portance, such  as  the  suppression  and  prevention  of  epidemics. 

The  Health  Ofl&cer. — The  local  executive  officer  is  the  health 
officer.  It  is  essential  that  he  be  a  trained  sanitarian,  and  in 
most  states  he  must  be  a  physician.  His  duties  will  depend 
largely  on  the  population  of  his  district  and  on  the  attitude  of  the 
public  toward  health  matters.  New  York  State  has  over  1000 
health  officers.  The  great  majority  of  them  are  in  rural  districts, 
in  each  of  which  the  health  officer  constitutes  almost  the  entire 
executive  force  of  the  health  department.  The  position  is  one  of 
responsibility,  and  demands  a  considerable  degree  of  skill  and 
more  than  ordinary  medical  knowledge  along  all  lines  of  public 
health  work.  The  efficiency  of  the  local  health  department  de- 
pends almost  entirely  on  the  health  officer. 

Poivers  of  the  Health  Officer. — The  local  health  officer  is 
charged  with  the  duty  of  enforcing  the  health  laws  that  apply 
to  his  district.  His  powers  are  strictly  limited  to  those  conferred 
on  him  by  the  statute  law  and  by  the  sanitary  codes  of  the  state 
and  of  his  district.  His  acts  are  subject  to  review  by  the  courts, 
and  he  is  personally  liable  for  acts  for  whose  authorization  there 
is  no  specific  law.  But  the  laws  and  the  code  are  sufficiently 
broad  to  enable  him  to  cope  with  every  condition  that  is  actually 
unsanitary,  and  the  health  officer  is  clothed  with  abundant  power 
to  remedy  practically  all  conditions  that  are  a  direct  menace  to 
Ufe  or  health. 

The  health  officer  has  no  power  over  conditions  which  do  not 
affect  health.  When  he  receives  a  complaint,  his  first  concern  is 
to  determine  whether  or  not  the  condition  has  an  effect  on  the 
health,  as  distinguished  from  the  feelings  and  wishes,  of  the  com- 
plainant. A  country  health  officer  receives  all  sorts  of  complaints 
about  conditions  which  do  not  affect  the  health  of  human  beings. 
Examples  of  these  complaints  are  those  about  sick  chickens, 
barking  dogs,  and  ash  heaps.  A  health  officer  sometimes  feels 
that  he  must  act  on  these  complaints,  for  he  is  often  the  only 
public  officer  whose  scope  of  work  is  at  all  related  to  the  subject 
of  the  complaint;  but  his  powers  are  no  more  than  those  of  any 
other  public-spirited  citizen,  except  that  the  prestige  of  his 
office  and  the  righteousness  of  his  cause  may  enable  him  to  se- 
cure remedies  when  other  persons  fail. 

A  health  officer  derives  part  of  his  authority  from  the  state 
laws  and  part  from  local  ordinances.     When  he  acts  under  a 


ORGANIZATION   AND   POWERS    OF  A   HEALTH   DEPARTMENT    21 

state  law  he  has  the  prestige  and  power  of  the  state  to  support 
him.  But  when  he  acts  under  a  local  ordinance  he  is  not  always 
sure  of  the  support  of  the  local  board  of  health.  If  he  has  the 
active  co-operation  of  his  board  of  health  he  may  be  reasonably 
sure  that  he  has  sufficient  power  to  carry  out  his  work.  If  the 
board  is  lukewarm  or  hostile,  he  can  do  little  under  the  local 
ordinances.  Whatever  he  does,  he  must  be  able  to  refer  to  a 
definite  section  of  a  law  or  code  which  specifically  covers  his  act. 
Failure  to  know  the  law  accurately  is  responsible  for  most  of  the 
legal  troubles  of  a  health  ofifiicer. 

While  some  health  officers  are  overzealous  and  are  inclined 
to  exceed  their  authority,  others  shirk  their  duty  and  refuse  to 
act  when  there  is  no  special  law  ordering  them  to  act  under  a 
particular  condition.  A  wise  health  officer  will  adopt  a  golden 
mean  of  action  between  zeal  and  timidity. 

PubHc  sentiment  and  the  courts  grant  almost  dictatorial 
powers  to  a  health  officer  in  the  presence  of  an  epidemic.  The 
same  powers  are  conceded  in  the  suppression  of  a  nuisance  in- 
volving offensive  odors,  for  many  people  still  cling  to  the  old  idea 
that  gaseous  emanations  breed  diseases.  The  public  is  not  al- 
ways willing  to  allow  him  power  over  disease  carriers  who  are 
apparently  healthy.  His  success  in  handhng  this  class  of  cases 
depends  on  having  proof  of  the  dangerous  conditions.  Mere 
suspicion  is  not  sufficient.  The  burden  of  proof  is  on  the  health 
officer,  and  he  must  have  sufficient  evidence  to  convict  if  the 
case  should  come  to  court. 

Police  Power. — The  duties  of  a  health  officer  often  require 
him  to  interfere  with  private  property  and  personal  liberty  of 
action.  For  example,  a  village  develops  around  the  barnyard 
of  a  farmer  who  claims  that  his  neighbors  voluntarily  settled 
around  him,  knowing  that  his  business  required  him  to  keep 
pigs,  cows,  and  chickens.  He  objects  to  the  investigations  of  the 
health  officer  and  claims  that  the  health  ofi&cer  has  no  right  to  tell 
him  how  to  run  his  barnyard.  The  principle  of  law  that  applies 
in  such  a  case  is  that  of  the  police  power  of  a  municipality.  The 
police  power  means  the  power  to  control  the  acts  and  property 
of  individual  persons  for  the  benefit  of  all  the  people  of  a  com- 
munity. This  is  one  of  the  fundamental  principles  in  law,  and 
its  application  to  health  departments  and  health  officers  has  been 
established  by  the  highest  courts  in  the  land.  Health  laws  and 
ordinances  are  founded  upon  the  principle  of  the  police  power  of 
the  state. 

Lines  of  Work. — A  health  officer  is  the  duly  authorized  person 
in  charge  of  the  public  health  work  in  his  municipahty.  This 
work  consists  in  the  control  of  those  conditions  which  are  likely 


22  ,  THE  HEALTH   OFFICER 

to  harm  the  health  of  others  besides  the  persons  who  are  respon- 
sible for  the  conditions.  The  health  officer  cannot  interfere 
with  the  liberty  of  choice  and  action  of  a  private  person  unless 
the  acts  are  likely  to  have  a  harmful  effect  on  the  health  of  a 
number  of  other  persons.  Public  health  work  originally  was 
merely  the  suppression  of  epidemics  of  contagious  diseases.  It 
was  then  extended  to  the  control  of  whatever  might  produce  an 
epidemic,  such  as  sewage  and  public  water-supplies.  Its  newer 
development  includes  all  unhealthful  conditions  and  practices, 
whether  the  diseases  which  they  produce  are  communicable  or 
not.  Examples  of  the  newer  lines  of  public  health  work  are  the 
control  of  child  labor  and  the  prevention  of  diseases  which  arise 
from  unhealthful  occupations. 

A  health  officer  is  an  all-round  practitioner  in  public  health. 
The  health  departments  of  the  larger  cities  develop  specialists 
in  each  line  of  work,  but  most  health  officers  are  like  general  prac- 
titioners in  private  practice,  and  must  do  all  kinds  of  public 
health  work.  A  country  health  officer  in  the  course  of  a  year  or 
two  will  have  to  deal  with  as  wide  a  range  of  problems  as  a  city 
health  officer,  but  he  will  have  very  few  cases  of  each  kind.  The 
standard  lines  of  work  which  a  local  health  department  is  expected 
to  conduct  under  the  super\dsionof  the  health  officer  are  as  follows: 

1.  Communicable  diseases — their  suppression  and  pre\Tn- 
tion. 

2.  Laboratories — the  collection  and  transmission  of  speci- 
mens for  diagnosis  and  investigation,  and  the  distribution  and 
administration  of  antitoxins  and  serums. 

3.  Nuisances — their  investigation  and  abatement. 

4.  Water-supplies — their  purity  and  purification. 

5.  Sewage  and  sewer  systems. 

6.  Milk-supplies  and  dairies — their  inspection  and  control. 

7.  Food  and  meat  inspections  and  the  control  of  slaughter 
houses,  butcher  shops,  and  grocery  stores. 

8.  Inspections  of  public  buildings. 

9.  Vital  statistics,  including  a  record  of  prevailing  diseases. 

10.  Medical  inspection  of  school  children  and  the  correction 
of  their  defects. 

11.  Infant  welfare  work. 

12.  Insanity,  commitments  to  hospitals,  and  preventive  work 
in  mental  hygiene. 

13.  Occupational  diseases,  dangerous  trades,  and  child  labor. 

14.  Educating  the  public  by  exhibits,  lectures,  circulars,  news- 
paper articles,  etc. 

15.  Clerical  work,  correspondence,  records,  and  reports. 

16.  Public  health  nursing. 


ORGANIZATION  AND   POWERS    OF   A   HEALTH   DEPARTMENT     23 

The  laws  sometimes  impose  duties  on  a  health  officer  arbi- 
trarily, probably  because  there  may  be  no  other  available  official 
to  do  the  work.  For  example,  the  New  York  State  laws  require 
the  health  oflicer  to  examine  children  for  labor  certificates,  to 
inspect  the  means  of  comfort  provided  to  women  clerks  in  stores, 
and  to  investigate  the  cause  of  death  of  persons  who  die  without 
medical  attendance,  and  to  supervise  the  commitment  of  the 
indigent  insane.  The  position  of  health  officer  is  one  of  constantly 
increasing  responsibility  and  scope  of  duties. 

The  Staff  of  a  Health  Officer. — The  staff  that  is  needed  to 
carry  on  the  various  lines  of  health  work  in  a  community  will 
depend  upon  the  population  of  the  district  and  upon  the  amount 
of  work  which  public  sentiment  demands  of  a  health  officer. 
Usually  a  health  officer  is  the  only  authorized  employee  of  the 
Health  Department  of  a  small  municipality,  and  he  gives  only 
a  part  of  his  time  to  the  work,  although  he  is  supposed  to  be  ready 
to  respond  to  public  health  calls  at  any  time.  Under  normal 
conditions  a  health  officer  can  do  all  the  public  health  work  for  a 
community  of  2000  or  3000  persons  without  undue  interference 
with  his  private  business.  If  a  population  is  more  than  3000,  a 
health  officer  will  be  burdened  with  petty  complaints  and  with 
sanitary  inspections  which  could  be  done  by  a  layman  as  well  as 
by  a  trained  sanitarian ;  but  a  part-time  health  officer  can  do  all 
the  medical  and  other  expert  work  for  a  community  of  10,000  or 
15,000  people  if  he  has  competent  laymen  for  assistants. 

The  assistants  which  a  health  officer  needs  may  be  divided 
into  three  classes:  1,  office  clerks;  2,  inspectors;  3,  public  health 
nurses. 

Clerks  to  the  Health  Officers. — Every  act  of  the  officials  of  the 
health  department  of  a  city  is  reported  in  detail,  and  the  annual 
summary  makes  an  impressive  array  of  figures.  Most  health 
officers  have  no  idea  how  many  inspections  they  make  or  how 
many  calls  upon  cases  of  contagious  disease.  They  do  their  work 
quietly  and  unostentatiously,  and  they  modestly  consider  an 
interview  with  a  person  on  the  street  to  be  not  worth  mentioning. 
A  reason  for  the  failure  of  the  public  to  appreciate  public  health 
work  is  that  health  officers  do  not  report  what  they  are  doing. 
Records  of  work  will  not  be  kept  satisfactorily  until  clerks  are 
provided  to  keep  them.  A  part-time  clerk  is  needed  for  every 
health  officer. 

A  health  department  usually  has  a  registrar  of  vital  statistics 
who  does  the  clerical  work  of  recording  births  and  deaths  and 
issuing  burial  permits,  but  this  officer  usually  acts  independently 
of  the  health  officer. 

Sanitary  Inspectors. — Every  health  officer  of  a  community 


24  THE   HEALTH    OFFICER 

of  over  3000  population  needs  a  sanitary  inspector  whom  he 
may  send  to  inspect  nuisances  and  unsanitary  conditions,  and 
serve  notices,  thus  relieving  the  health  officer  of  the  burden  of 
the  inexpert  field  work.  He  will  be  the  agent  of  the  health  officer 
in  making  teinspections  and  seeing  that  the  orders  of  the  health 
officer  are  carried  out.  The  work  of  a  health  officer  is  often  a 
failure  because  no  one  is  charged  with  the  duty  of  following  up 
his  original  visits  and  seeing  that  his  directions  are  understood 
and  obeyed. 

Public  Health  Nurse. — Every  community  of  over  3000  peo- 
ple needs  a  public  health  nurse.  She  may  also  do  much  work 
as  sanitary  inspector.  She  is  an  inspector  and  instructor  of 
persons,  while  the  sanitary  inspector  deals  with  their  environ- 
ment. The  nurse  is  almost  indispensable  to  a  health  officer  who 
wishes  to  do  constructive  work.  The  only  health  officers  who 
object  to  public  health  nurses  are  those  who  wish  to  do  only 
routine  work  along  traditional  lines. 

The  ideal  official  staff  for  a  country  health  officer  will  consist 
of  a  part-time  clerk,  a  part-time  inspector,  and  a  full-time  public 
health  nurse.  A  health  officer  can  also  employ  helpers  in  emer- 
gencies, such  as  watchers  at  quarantined  houses,  and  scavengers 
to  clean  up  unsanitary  premises,  provided  their  employment  is 
authorized  by  the  health  board.  If  a  health  officer  does  not  go 
to  his  board  of  health  for  the  employment  of  his  helpers,  he  may 
have  to  pay  them  out  of  his  own  pocket. 

The  members  of  a  board  of  health  are  usually  willing  to  go 
with  a  health  officer  to  make  inspections  in  difficult  cases  and  to 
assist  him  in  the  discharge  of  his  duties,  but  they  are  not  required 
to  do  this  work. 

Unofficial  Helpers. — Most  communities  now  have  societies 
for  the  improvement  of  civic  conditions.  These  organizations 
are  composed  of  public-spirited  persons  who  are  willing  to  assist 
the  health  officer  and  to  educate  the  public  in  favor  of  his  work. 
They  also  provide  funds  for  carrying  on  advanced  lines  of  public 
health  work,  such  as  pubHc  health  nursing.  Boards  of  health 
are  usually  willing  to  allow  a  health  officer  to  do  advanced  work 
so  long  as  it  does  not  cost  them  money.  The  usual  way  in  which 
advanced  work  is  undertaken,  even  in  large  cities,  is  by  an  organ- 
ization providing  the  funds  to  support  the  work  until  boards 
of  health  and  the  people  recognize  its  value  and  necessity,  and 
appropriate  the  funds  to  support  it.  A  health  officer  will  find 
civic  organizations  to  be  his  best  aids. 


CHAPTER   II 
THE   HEALTH   OFFICER   HIMSELF 

Public  Health  Work  a  Specialty. — Public  health  work  is  a 
new  specialty  in  medicine,  and  outside  of  cities  its  practice  is 
confined  almost  entirely  to  part-time  health  officers.  It  calls 
for  more  skill  and  knowledge  than  the  average  doctor  possesses. 
A  health  officer  is  a  public  health  specialist  whom  the  physicians 
in  his  jurisdiction  are  compelled  to  consult.  His  opinion  has  a 
legal  as  well  as  a  medical  value,  for  it  will  often  determine  the 
hberty  of  a  whole  household  for  days  or  weeks.  The  position  of 
health  officer  is  always  one  of  responsibility.  It  will  also  be  one 
of  honor  and  respect  if  it  is  attained  by  careful  study  and  con- 
scientious practice  and  experience. 

The  health  officer  is  the  medical  adviser  of  the  community  in 
matters  of  public  health.  The  public  is  often  as  unreasonable 
and  as  exacting  as  a  nervous  patient,  and  the  successful  health 
officer  must  be  as  wise  and  diplomatic  with  the  community  as 
a  nerve  specialist  with  a  neurasthenic.  The  health  officer  often 
finds  it  difficult  to  give  satisfaction  in  his  dual  position  as  consult- 
ant to  the  family  physician  and  as  public  medical  adviser.  For 
example,  the  parent  of  a  diphtheria  carrier  often  resents  the 
restriction  of  the  liberty  of  an  apparently  well  child,  even  though 
the  restriction  is  necessary  for  the  protection  of  the  public. 
Satisfying  the  conflicting  interests  of  his  two  clients  requires  a 
combination  of  judgment,  knowledge,  and  diplomacy  that  can 
come  only  from  exact  observation  and  thoughtful  experience. 

A  family  doctor  frequently  owes  his  success  to  his  ability  to 
please  his  families,  regardless  of  his  ability  and  knowledge. 
This  ability  to  please  is  a  most  important  asset  for  a  health 
officer  as  well  as  for  a  family  physician.  A  health  officer  must 
know  the  needs  and  the  peculiarities  of  his  community,  and  must 
have  special  skill  in  treating  and  satisfying  the  public,  just  as  a 
specialist  in  any  other  line  of  medicine  must  have  skill  in  hand- 
ling the  class  of  patients  which  come  to  him.  A  pleasing  and 
yet  convincing  manner  of  dealing  with  the  public  is  necessary 
for  a  health  officer's  success. 

Preparation  for  Public  Health  Work. — ^A  physician  is  not 
qualified  to  be  a  health  officer  merely  because  he  is  successful  in 
private  practice.     The  position  requires  special  skill  and  expe- 

25 


26  THE    HEALTH    OFFICLU 

rience  in  subjects  of  which  private  physicians  have  no  time  or 
occasion  to  make  a  special  study.  For  example,  each  private 
physician  in  a  rural  district  will  see  only  2  or  3  cases  of  diphtheria 
in  a  year,  and  will  have  no  occasion  to  devote  special  time  to  a 
study  of  the  disease.  A  health  officer  will  see  all  the  cases  that 
occur  in  the  district  and  will  be  expected  to  be  able  to  advise 
family  physicians  in  all  phases  of  the  subject  of  diphtheria. 

The  knowledge  and  skill  of  a  health  officer  will  depend  largely 
on  his  love  for  the  work.  If  a  ph}'sician  is  public  spirited,  he 
will  naturally  do  some  public  health  work  because  he  likes  it. 
The  best  health  officers,  like  the  best  surgeons,  are  general  prac- 
titioners who  gradually  devote  more  and  more  time  to  the  study 
of  public  health  until  they  acquire  a  proficiency  in  it.  The  pro- 
portion of  health  officers  who  are  successful  is  about  the  same 
as  that  of  successful  specialists  in  other  lines  of  medicine. 

A  great  difficulty  in  pubhc  health  work  has  hitherto  been  a 
lack  of  exact  knowledge  of  the  nature  of  infectious  diseases  and 
of  the  manner  in  which  they  spread.  A  health  officer's  work 
formerly  consisted  mainly  in  enforcing  strict  quarantine  and  in 
cleaning  up  nuisances  which  were  olTensive  to  the  sense  of  smell. 
This  was  chiefly  clerical  and  could  have  been  done  by  one  doctor 
as  well  as  by  another;  or  even  by  a  la>Tnan,  for  no  special  knowl- 
edge was  required.  But  today  we  possess  a  vast  amount  of 
exact  knowledge  concerning  infectious  diseases,  and  in  many  dis- 
eases this  knowledge  is  sufficiently  complete  to  make  sanitary 
and  preventive  medicine  exact  sciences.  The  detection  of  many 
diseases  is  now  made  by  means  of  exact  laboratory  tests  with 
which  a  health  officer  must  be  familiar,  even  though  he  cannot 
actually  perform  the  tests.  Trained  workers  in  the  laboratories 
of  state  and  national  governments  and  in  endowed  institutions 
for  research  are  constantly  making  discoveries  and  applying  them 
to  the  detection  and  treatment  of  diseases,  and  the  results  are 
pubhshed  freely  for  the  public  benefit.  A  health  officer  who  is  a 
year  or  two  in  arrears  in  his  knowledge  cannot  do  his  full  duty, 
and  his  deficiency  in  knowledge  is  likely  to  cost  lives.  If  a 
health  officer  is  five  years  behind  the  advanced  knowledge  of  the 
da}',  he  is  hopelessly  behind  the  times. 

The  health  departments  of  the  states  and  of  the  larger  cities 
provide  free  laboratory  facilities  for  diagnosis,  and  make  pro- 
vision to  supply  the  materials  for  the  treatment  of  many  diseases. 
The  local  agent  for  a  department  is  the  health  officer.  He  must 
know  how  to  obtain  material  for  the  laboratory  tests,  how  to 
interpret  the  reports,  and  how  to  apply  the  treatments  which  are 
sent  out  by  the  experts  in  the  laboratories.  A  community  has 
a  right  to  demand  that  its  health  officer  shall  be  able  to  make  use 


THE   HEALTH    OFFICER   HIMSELF  27 

of  the  facilities  which  are  provided  for  diagnosis  and  treatment 
and  that  he  keep  himself  informed  regarding  recent  advances  in 
sanitary  science. 

One  of  the  surprising  things  in  public  health  work  is  the 
sudden  development  of  new  phases  of  old  diseases.  An  example 
is  the  development  of  extensive  epidemics  of  septic  sore  throat 
chiefly  as  the  result  of  the  concentration  of  milk  production  in 
large  dairies.  Another  example  is  the  sudden  development  of 
virulence  in  the  germs  in  pohomyeKtis  in  1916.  A  health  officer 
may  be  confronted  with  a  unique  problem  on  which  he  will  fail 
unless  he  keeps  himself  well  informed  and  up  to  date  in  medicine 
and  epidemiology.  This  knowledge  and  expertness  can  be  main- 
tained only  by  constant  reading  and  study.  A  physician  who 
has  not  given  special  study  to  sanitary  science  is  not  qualified 
to  be  a  health  ofificer;  and  a  health  officer  who  ceases  to  study, 
or  to  keep  abreast  with  the  current  publications  on  public  health, 
or  who  fails  to  attend  meetings  and  conferences  of  sanitary 
workers,  is  not  qualified  to  retain  his  position.  New  York 
State  requires  every  health  officer  to  take  a  special  course  of 
instruction  in  public  health. 

The  Health  Officer  a  Leader.^ — Certain  duties  are  imposed 
by  law  on  a  health  officer.  He  is  to  perform  some  of  those  duties 
on  his  receipt  of  reports  of  the  existence  of  contagious  diseases 
or  of  complaints  of  nuisances.  Some  health  officers  take  a  pass- 
ive attitude,  and  act  only  on  receipt  of  reports  or  of  complaints. 
But  a  health  officer  must  be  something  more  than  a  passive 
agent.  He  must  be  a  leader.  One  who  does  his  duty  must  seek 
for  missed  cases  of  contagious  disease,  make  inspections  to  dis- 
cover nuisances,  and  urge  physicians  and  other  public  health 
workers  to  undertake  new  lines  of  work.  Instead  of  waiting  for 
the  people  to  ask  him  to  do  his  work,  he  will  wake  the  people  up 
to  do  their  duty. 

Some  of  the  newer  health  laws  impose  certain  duties  of  in- 
itiating work  upon  the  health  officers.  For  example,  the  New 
York  State  health  laws  require  health  officers  "to  make  an  annual 
sanitary  survey  and  maintain  a  continuous  sanitary  supervision 
over  the  territory  within  their  jurisdiction." 

The  most  evident  duty  of  a  health  officer  is  to  suppress  epi- 
demics, and  to  this  duty  he  is  spurred  on  by  the  complaints  of 
the  public.  But  a  modern  health  officer  is  expected  to  prevent 
epidemics  from  developing.  He  is  expected  to  save  the  lives  of 
babies,  to  prolong  the  lives  of  adults,  and  to  promote  the  health 
and  comfort  of  everybody  in  the  community.  He  must  rouse 
those  who,  through  ignorance  or  self-satisfaction,  do  not  wish  to 
be  disturbed.     This  work  will  be  accomplished  not  by  spas- 


28  THE   HEALTH    OFFICER 

modic  effort,  but  by  a  continuous,  well-balanced  activity,  founded 
on  knowledge  and  backed  by  conviction.  The  successful  health 
officer  is  a  prophet  in  the  old  meaning  of  the  word,  signifying  one 
who  speaks  forth.  He  is  a  leader  in  sanitary  progress  in  his  com- 
munity. He  seeks  to  improve  social  conditions  which  foster 
physical  defects  and  sickness.  He  is  also  a  physician  to  the 
strong  and  the  well,  and  seeks  to  maintain  a  high  standard  of 
health  and  efficiency  in  a  community.  The  next  great  develop- 
ment in  medical  practice  will  be  the  treatment  of  the  well,  and 
in  this  movement  the  leaders  will  be  the  health  officers. 

The  Health  Officer  an  Educator.— A  health  officer  is  de- 
pendent on  the  response  of  the  people  to  his  appeals  and  on  the 
support  of  the  public  when  he  undertakes  new  lines  of  work. 
In  the  ordinary  course  of  events  it  takes  about  twenty  years  for 
knowledge  of  a  medical  discovery  to  spread  through  society  and 
to  become  a  matter  of  common  thought.  But  most  Depart- 
ments of  Health  carry  on  campaigns  of  education  in  order  that 
a  knowledge  of  sanitary  discoveries  may  immediately  be  spread 
to  the  public  as  well  as  to  physicians.  They  also  make  elabor- 
ate provision  for  educating  the  public  along  health  Hnes,  in  order 
that  the  people  will  not  only  support  the  departments  in  insti- 
tuting new  work  and  improving  the  old,  but  also  that  they  will 
improve  their  own  sanitary  habits.  The  ideal  condition  in  a 
community  is  that  the  people  are  educated  to  such  a  degree  that 
they  habitually  do  those  things  which  the  departments  of  health 
now  force  them  to  do. 

A  health  officer  is  a  pubhc  educator,  and  his  success  will  de- 
pend largely  on  his  abihty  to  make  the  public  understand  the 
reasons  for  his  acts  and  advice.  It  is  the  duty  of  a  health  officer 
to  make  use  of  every  case  of  contagious  disease  and  of  every  com- 
plaint to  explain  the  sanitary  principles  that  are  involved,  and 
to  prove  the  desirability  as  well  as  the  necessity  for  his  orders. 
If  he  is  a  ready  speaker,  he  will  deliver  addresses  on  sanitation. 
If  he  is  a  facile  writer,  the  local  newspapers  will  use  his  copy. 
The  laws  of  some  of  the  states  impose  educational  duties  on 
health  officers. 

A  health  officer  has  a  higher  object  than  merely  preventing 
physical  diseases  and  suppressing  epidemics.  Physical  sickness 
and  bodily  defects  dull  the  mind  and  blight  the  soul,  and  the 
health  officer  who  preaches  public  health  serves  the  people  in 
the  same  way  as  the  teacher  and  the  minister  of  the  gospel. 
A  health  officer  has  missed  his  calling  if  he  is  not  actuated  by  a 
missionary  motive  and  a  sincere  desire  to  strengthen  mankind 
not  only  in  body  but  also  in  mind  and  spirit. 

Relation  to  Physicians. — The  health  officer  stands  in  a  pecu- 


THE   HEALTH    OFFICER   HIMSELF  29 

liar  relation  to  other  physicians  in  that  they  are  compelled  to 
consult  him  and  to  allow  him  to  see  their  cases  of  contagious  dis- 
eases. This  relation  offers  great  opportunities  to  the  efficient 
health  officer,  but  it  is  the  source  of  endless  disputes  if  he  is  dicta- 
torial and  critical  to  the  family  physician  or  is  deficient  in  abil- 
ity. The  co-operation  of  physicians  is  absolutely  necessary  in 
doing  efficient  health  work.  One  of  the  distinct  duties  of  a 
health  officer  is  to  study  to  secure  that  co-operation.  The  health 
officer  is  himself  in  great  need  of  training  and  mental  discipline 
if  he  is  unable  to  hold  the  good  will  of  his  medical  colleagues. 
He  must  remember  that  physicians  are  not  expected  to  have 
skill  in  sanitation  to  as  great  a  degree  as  he,  and  he  must  freely 
place  his  knowledge  at  their  disposal.  He  must  help  them  out  of 
difficulties  and  show  them  the  newer  methods  of  handling  com- 
municable diseases.  He  will  be  active  in  medical  societies,  and 
will  take  every  occasion  to  promote  good  fellowship  among 
physicians. 

An  efficient  health  officer  can  do  much  to  assist  and  instruct 
the  physicians  of  a  community.  He  will  be  acquainted  with  the 
workers  in  public  laboratories,  and  will  know  how  to  forward 
specimens  to  them  promptly.  He  will  know  how  to  give  anti- 
toxins ;  how  to  intubate ;  how  to  do  spinal  punctures ;  how  to  give 
intravenous  injections;  and  how  to  secure  the  admission  of 
patients  to  hospitals.  He  will  be  familiar  with  the  early  signs 
of  tuberculosis.  He  will  know  something  of  sanitary  engineer- 
ing and  sewage  disposal.  He  will  understand  the  production  of 
pure  milk  and  the  prevention  of  milk-borne  diseases.  He  will 
be  familiar  with  the  relation  of  social  conditions  to  malnutrition 
and  defects  among  school  children.  There  is  a  large  and  varied 
field  in  which  a  health  officer  is  expected  to  offer  special  assist- 
ance to  his  medical  colleagues. 

Relation  to  Lay  Societies. — Every  progressive  idea  is  born 
in  the  brain  of  an  individual  from  whom  it  spreads  like  a  contagion 
until  it  pervades  a  whole  community.  A  new  idea  in  the  ad- 
ministration of  sanitary  affairs  is  usually  introduced  into  a 
community  by  an  earnest  person  who  persuades  his  friends  of 
the  value  of  the  new  line  of  work,  and  they  form  an  organization 
to  finance  it  and  give  it  a  trial.  Finally,  when  the  community 
becomes  convinced  of  its  value,  the  legal  body  of  officials  as- 
sumes the  work  at  public  expense.  The  members  of  village 
improvement  societies,  charitable  organizations,  granges,  boards 
of  trade,  and  women's  clubs  are  usually  anxious  to  be  leaders  in 
progressive  movements,  especially  those  for  the  rehef  of  suffer- 
ing. The  health  officer  can  usually  find  an  existing  organization 
that  will  support  him  in  his  progressive  poHcies,  and  will  finance 


30  THE   HEALTH    OFFICER 

them  during  a  period  of  experiment  and  trial.  The  societies 
may  annoy  a  health  officer  \vho  is  unprogressive  and  inactive, 
but  a  health  officer  who  fails  to  co-operate  with  them  or  to  direct 
their  public  health  activities  neglects  a  great  opportunity,  for 
they  may  be  invaluable  aids  in  promoting  his  work. 

Activities  of  a  Health  Officer. — The  standard  lines  of  work 
which  are  conducted  by  a  local  health  department  are  enumer- 
ated on  page  22.  The  health  officer  is  the  director  of  all  these 
various  activities,  and  he  often  constitutes  the  entire  field  force 
of  the  municipality.  He  is  a  combination  of  health  commissioner, 
medical  expert,  clerk,  plumbing  inspector,  legal  adviser,  and 
chief  of  the  sanitary  police.  Whatever  is  done,  he  must  either 
do  it  himself  or  personally  oversee  it.  Whenever  an  emergency 
arises,  he  must  create  an  organization  w^hich  will  cease  to  exist 
as  soon  as  conditions  are  again  normal.  The  small  volume  of 
work  in  any  particular  line  does  not  justify  its  systematic  organ- 
ization, but  he  attends  to  his  public  health  duties  as  a  side  issue 
to  his  regular  practice. 

The  activities  of  a  health  officer  may  be  divided  into  field 
w^ork  and  office  duties.  Most  of  the  actual  work  of  preventing 
diseases  and  remedying  unsanitary  conditions  is  done  in  the 
field,  and  a  health  officer  can  perform  these  duties  without  doing 
office  w^ork.  But  he  must  consider  more  than  the  immediate 
duty  of  the  hour.  The  people  look  to  him  for  information  and 
instruction.  They  pay  the  bills  which  he  contracts,  and  they 
have  a  right  to  know^  about  his  activities.  If  the  health  officer 
fails  to  inform  the  people  of  their  needs  and  of  the  measures 
which  he  has  taken  for  their  protection,  he  cannot  blame  them 
for  their  ignorance  of  his  work  and  for  their  prejudice  against 
modern  innovations  in  sanitation.  He  has  a  duty  to  keep  the 
people  informed  regarding  health  conditions  in  his  district,  and 
he  can  do  this  only  by  devoting  a  considerable  time  to  office  ac- 
tivities. These  activities  may  be  classified  as:  1,  Records  and 
reports;  2,  correspondence;  3,  telephone  calls;  4,  vital  statistics; 
5,  educational;  6,  conferences;  7,  study. 

Records  and  Reports. — If  a  record  of  every  little  act  done  by 
a  health  officer  were  kept,  the  total  would  probably  surprise  the 
public,  the  board  of  health,  and  the  health  officer  Jhimself.  The 
health  officer  often  considers  that  the  incidental  inspections  and 
warnings  cost  him  little  effort,  and  he  prefers  to  forget  them 
rather  than  to  go  to  the  trouble  of  recording  them.  This  lack 
of  records  accounts  in  large  measure  for  the  failure  of  boards  of 
health  and  of  the  public  to  appreciate  his  work.  The  act  of 
keeping  a  record  of  his  work  lends  dignity  and  importance  to  his 
position  both  in  his  own  estimation  and  in  that  of  the  board  of 


THE   HEALTH    OFFICER   HIMSELF  31 

health  and  the  public.  A  health  officer  will  receive  recognition 
for  the  work  which  the  public  knows  that  he  has  done.  If  the 
public  does  not  know  of  his  work,  the  health  officer  has  no  ground 
for  the  frequently  expressed  complaint  that  his  work  is  not 
recognized.  A  health  officer  owes  it  both  to  himself  and  to  the 
public  to  keep  a  record  of  every  item  of  duty  that  he  performs. 

The  pay  of  a  health  officer  cannot  be  based  on  a  fixed  amount 
per  call  as  in  private  practice,  but  it  is  best  estimated  by  the 
time  spent  in  the  work.  Health  officers  are  usually  underpaid, 
but  very  few  of  them  can  demonstrate  the  fact  by  actual  records 
of  the  time  spent  in  performing  each  kind  of  work.  The  New 
York  State  Department  of  Health  is  trying  to  secure  a  record  of 
the  time  spent  by  each  health  officer  in  the  performance  of  public 
health  work,  including  office  work,  in  order  to  form  an  estimate 
of  what  is  a  proper  remuneration  for  him.  It  is  desirable  that  a 
system  of  grading  health  officers  be  developed,  based  on  the  pop- 
ulation of  their  districts,  the  character  of  the  work  that  needs 
to  be  done,  their  personal  initiative  in  developing  the  work,  and 
their  efficiency  in  getting  results.  This  can  be  done  only  after 
accurate  records  are  secured.  These  records  need  not  be  elab- 
orate, but  they  must  be  complete  and  include  items  which  health 
officers  often  overlook  and  forget. 

Correspondence. — A  large  amount  of  mail  relating  to  his 
work  comes  to  every  health  officer.  He  has  requests  for  assist- 
ance and  instructions  from  people  living  in  distant  parts  of  his 
district,  and  for  information  from  investigators,  societies,  teach- 
ers, and  others  who  are  interested  in  pubhc  health  work.  His 
state  department  of  health  often  asks  him  to  make  reports  on 
special  work  done,  and  on  complaints  which  come  to  the  central 
office.  Letter  writing  is  often  dull  work,  and  is  usually  reckoned 
as  a  gratuitous  activity,  but  it  is  important.  A  health  officer 
neglects  his  opportunities  if  he  does  not  answer  each  inquiry 
and  letter  promptly,  courteously,  and  fully. 

It  is  an  excellent  plan  for  a  health  officer  to  preserve  each 
letter  he  receives,  to  endorse  it  with  a  brief  note  of  the  date  of 
answering  it,  and  to  place  it  on  a  letter  file.  Any  health  officer 
can  easily  do  this  even  when  he  has  to  write  the  replies  with  his 
own  hand.  It  is  also  desirable  for  him  to  retain  carbon  copies  of 
his  replies. 

Telephone  Calls. — Every  health  officer  receives  and  makes 
numerous  official  calls  over  the  telephone.  These  calls  are  often 
as  important  as  correspondence.  They  come  at  all  hours,  and 
are  often  a  source  of  great  annoyance,  and  a  health  officer  may 
justly  consider  that  he  is  entitled  to  receive  pay  for  the  time 
that  he  spends  at  the  telephone. 


32  THE   HEALTH   OFFICER 

Vital  statistics. — The  records  of  diseases,  deaths,  and  births 
are  the  basis  for  judging  efficiency  in  public  health  work.  An 
annual  estimation  of  death,  birth,  and  communicable  disease 
rates  for  his  municipaUty  is  one  of  the  duties  of  every  health 
officer,  for  these  rates  are  the  means  by  which  a  comparison  of 
the  health  work  in  various  districts  is  made  all  over  the  world. 

Educational. — Every  health  officer  is  compelled  to  do  work 
which  may  be  classed  as  educational.  He  receives  newspaper 
reporters  and  writes  news  items  for  them.  He  arranges  lectures 
and  exhibits,  and  takes  photographs  and  makes  lantern  slides 
illustrating  public  health  conditions.  He  prepares  lectures  and 
papers  for  medical  societies  and  writes  articles  for  medical  jour- 
nals. He  consults  experts  and  contractors  regarding  public 
works.  All  these  educational  activities  consume  time  and  re- 
quire expert  thought. 

Conferences. — A  health  officer  spends  considerable  time  in 
receiving  calls  from  his  superior  officers,  and  in  seeking  advice 
from  them.  He  attends  official  conferences  of  the  health  officers 
of  his  district  or  state,  and  he  holds  consultations  with  officials  of 
related  societies,  such  as  churches,  charitable  organizations,  and 
scientific  societies.  One  of  the  greatest  benefits  from  these  confer- 
ences is  the  inspiration  that  comes  from  his  personal  contact  with 
other  health  workers.  A  health  officer  is  entitled  to  credit  for 
the  conferences  and  consultations  in  which  he  engages. 

Reading  and  Study. — Books  and  journals  on  public  health 
topics  are  among  the  tools  with  which  a  health  officer  works. 
He  must  constantly  acquire  new  ideas  in  order  to  keep  abreast 
of  the  times  and  be  able  to  do  up-to-date  public  health  work. 
Studying  is  not  to  be  taken  as  evidence  of  deficiency  either  in 
instinctive  knowledge  and  natural  ability  or  in  previous  educa- 
tion. It  is  the  evidence  of  an  active  mind  and  of  interest  in 
public  health  matters.  The  time  which  a  health  officer  devotes 
to  study  is  spent  in  the  discharge  of  a  necessary  public  duty 
for  which  he  may  properly  be  recompensed.  A  health  officer 
may  be  judged  by  the  studying  which  he  does,  for  it  represents 
the  amount  of  serious  thought  which  he  gives  to  his  work 
and  his  degree  of  devotion  to  preventive  medicine  and  public 
health. 

Judging  a  Health  Officer. — A  health  officer's  success  depends 
on  the  man  himself.  The  office  will  not  run  itself,  but  public 
health  work  will  be  accomplished  in  direct  proportion  to  the 
ability  and  qualifications  of  the  man  at  its  head.  Since  he  often 
cornprises  the  entire  health  force  of  a  community,  the  health 
officer  must  be  a  man  of  many  parts  and  possess  varied  qualifi- 
cations and  accomplishments.     The  following  is  a  list  of  the  prin- 


THE   HEALTH    OFFICER   HIMSELF  33 

cipal  points  to  be  considered  in  judging  a  physician's  fitness  to 
be  a  health  officer : 

Knowledge 

Comparison  with  that  of  neighboring  physicians. 

Medical  journals  taken  or  read. 

Attendance  at  medical  society  meetings. 

General  education. 

Success  in  private  practice. 

Ability  as  a  public  speaker. 

Ability  as  a  writer. 

Initiative 
Abihty  as  a  leader. 

Reputation  for  doing  only  what  he  is  forced  to  do,  or  only 
what  he  is  invited  to  do,  and  for  planning  original  work. 
Practical  or  idealistic. 

Adaptability 

Reputation  for  working  with  other  physicians. 
Co-operation  with  social  agencies  (schools,  churches,  civic 
societies). 

General  sociability. 

Willingness  to  do  any  kind  of  work. 

Willingness  to  take  advice. 

Personality 
Personal  appearance. 
Overbearing,  or  meek. 
Courageous,  or  time  serving. 

Talkative,  or  a  good  listener.  ' 

Methodical,  or  careless. 
Objectionable  peculiarities  or  habits. 

Character  and  Reputation 
Uprightness. 

Payment  of  personal  bills. 
Public  spirited  or  selfish. 
Optimist,  or  pessimist. 

Outside  Interests  which  Might  Afect  His  Usefulness 

Business  projects. 
Sporting  proclivities. 
Hobbies. 
Philanthropic  associations. 


CHAPTER   III 
THE   LOCAL   BOARD    OF   HEALTH 

Need  for  a  Local  Board  of  Health. — There  are  three  essentials 
in  carrying  on  local  health  work:  first,  expert  health  officials; 
second,  money;  third,  favorable  public  sentiment.  Expert 
health  officers  often  fail  because  the  people  do  not  support  them 
with  their  purses  and  their  influence.  The  people  can  give 
official  support  to  a  health  officer  in  two  ways:  first,  by  voting 
him  funds  to  carry  on  his  work;  second,  by  standing  by  him  when 
violators  of  the  health  ordinances  are  brought  before  the  courts. 
The  power  of  the  people  to  hinder  public  health  work  is  fre- 
quently exercised  either  by  withholding  public  funds  or  by  re- 
fusing to  convict  offenders  against  the  laws. 

The  frequent  failure  of  the  people  to  support  the  local  health 
officer  has  led  some  states  to  adopt  the  plan  of  conducting  all 
health  affairs  either  entirely  by  the  state,  or  jointly  by  the  state 
and  the  counties,  in  order  to  remove  the  work  from  the  influence 
of  local  ignorance,  jealousy,  and  prejudice.  But  whatever  may 
be  the  details  of  the  organization  of  a  local  district,  the  health 
officer  must  depend  on  the  local  courts  of  law  and  on  chance  juries 
of  laymen  to  enforce  the  health  ordinances.  The  people  must 
take  part  in  the  administration  of  public  health  work  whether 
they  wish  to  do  so  or  not.  It  is  in  keeping  with  the  spirit  of 
American  institutions  that  the  people  in  each  municipality 
should  be  represented  in  public  health  work  by  a  local  board  of 
health.  If  a  health  officer  receives  the  support  of  his  local  board 
of  health,  he  may  confidently  rely  on  the  support  of  the  people. 

Composition  of  a  Board  of  Health. — The  membership  and 
the  methods  of  choosing  the  members  of  boards  of  health  vary 
widely  in  different  states.  In  New  York  the  board  in  a  town  is 
composed  of  the  town  board,  and  in  a  village,  of  the  village  board 
of  trustees.  But  in  cities  the  duties  are  so  many  and  various 
that  public  health  work  is  entrusted  to  a  special  board  of  health 
whose  members  are  usually  appointed  by  the  mayor. 

The  members  of  the  health  boards  of  villages  and  towns  are 
usually  business  men  who  have  no  special  knowledge  of  sanita- 
tion or  of  the  administrative  problems  of  public  health.  They 
represent  the  average  attitude  of  the  people  of  a  community 

34 


THE    LOCAL  BOARD    OF   HEALTH  35 

toward  public  health.  They  arc  likely  to  follow  the  American 
plan  that  office-holders  shall  reflect  public  opinion  rather  than 
mold  it.  They  are,  therefore,  likely  to  get  the  reputation  of 
retarding  progress  in  local  sanitation  rather  than  of  being  leaders 
in  public  health  work.  Yet  there  is  a  great  advantage  that  a 
local  board  of  health  shall  be  composed  of  average  laymen  of  a 
community,  for  if  the  members  of  the  board  are  not  convinced 
of  the  value  of  a  line  of  work,  much  less  will  the  general  public 
support  the  work.  The  success  of  constructive  public  health 
work  in  the  United  States  depends  on  public  sentiment  and  not 
on  force  impressed  on  the  people  from  above.  A  local  board  com- 
posed of  members  with  open  minds  will  broaden  the  field  of  local 
public  health  activities  as  soon  as  the  general  public  is  prepared 
to  support  the  work. 

Relation  of  a  Health  Officer  to  the  Board  of  Health. — The 
health  officer  stands  in  the  same  relation  to  a  board  of  health 
that  the  manager  of  a  factory  dogs  to  its  board  of  directors.  He 
represents  the  medical  and  scientific  side  of  public  health  work; 
the  board  of  health  represents  the  legal,  political,  and  business 
sides.  The  health  officer  diagnoses  pubhc  ills  and  prescribes 
treatment  for  the  community  as  his  patient.  The  health  board 
represents  the  public  in  accepting  or  rejecting  his  diagnosis  and 
treatment.  The  private  physician  frequently  is  unable  to  con- 
vince a  patient  of  impending  disease.  Likewise  a  health  officer 
often  has  difficulty  in  convincing  the  public  of  impending  dangers 
to  public  health.  Health  boards  are  the  guardians  of  public 
health  in  the  same  sense  that  parents  are  the  guardians  of  the 
health  of  their  children.  They  are  very  willing  to  consult  ex- 
perts when  a  serious  epidemic  breaks  out,  but  they  are  not 
always  so  willing  to  undertake  preventive  work  when  no  im- 
mediate and  evident  danger  is  in  sight. 

A  board  of  health  usually  adopts  one  of  three  attitudes  toward 
a  health  officer.  The  first  attitude  is  to  consider  the  health 
officer  and  his  work  as  a  joke.  The  trained  health  officer  sees 
danger  afar  ofif,  and,  because  it  is  not  nigh  at  hand,  the  board  of 
health  is  likely  to  ignore  the  warning  and  to  consider  preventive 
measures  to  be  infringments  on  private  privilege  and  personal 
liberty.  The  average  American  community  expects  to  offer  up 
a  sacrificial  toll  of  human  lives  and  suffering  to  its  god  of  personal 
independence  before  the  deity  is  appeased,  and  the  public  wakes 
up  to  its  duty  of  preventing  disease  while  the  task  is  still  small. 
It  is  difficult  for  a  health  officer  to  maintain  a  respectful  dignity 
of  manner  and  a  convincing  balance  of  speech  in  the  face  of  sar- 
casm and  jokes  about  his  pohcies  and  suggestions.  But  this 
attitude  of  indifference  is  rapidly  disappearing  under  the  influ- 


36  THE  HEALTH   OFFICER 

ence  of  educational  work  and  of  demonstrations  of  efficient  work 
by  health  officers.  The  most  convincing  of  all  arguments  is  the 
record  of  actual  results  of  public  health  work. 

A  second  attitude  of  a  board  of  health  is  one  of  panic  in  the 
presence  of  an  actual  epidemic,  and  of  indifTerence  between  epi- 
demics. When  the  hand  of  affliction  and  death  is  laid  on  a  few 
prominent  people,  a  board  of  health  and  a  community  will  take 
extreme  and  unnecessary  measures  to  stop  the  spread  of  sick- 
ness. For  example,  when  a  mild  case  of  smallpox  was  discovered 
in  a  certain  rural  town  of  3000  inhabitants,  the  patient  was  re- 
moved to  an  isolated  house  and  then  the  wagon  in  which  he  rode 
was  burned  and  the  horse  was  shot  by  order  of  the  board  of 
health.  But  the  attitude  of  fear  and  panic,  Hke  that  of  indiffer- 
ence, is  rapidly  changing  to  confidence  in  the  wisdom  and  abil- 
ity of  the  health  ofiicers. 

A  third  attitude  of  a  board  of  health  is  that  of  co-operation 
with  the  health  officer.  The  New  York  State  public  health  law 
reads  that  a  board  of  health  shall  direct  a  health  officer  in  the 
performance  of  his  duties,  but  conditions  are  usually  reversed, 
and  the  health  officer  directs  the  board  of  health.  The  ideal 
relation  is  that  the  health  officer  shall  feel  free  to  discuss  health 
affairs  with  his  board  of  health,  and  that  the  board  shall  give  a 
respectful  consideration  to  his  proposals.  An  active  health 
officer  will  plan  for  the  future,  and  will  suggest  more  lines  of 
work  than  can  be  attempted  at  once.  He  can  readily  annoy  a 
board  of  health  by  too  great  a  show  of  zeal  and  versatility,  and 
by  insisting  on  starting  reforms  before  the  public  is  prepared  to 
accept  them.  The  health  officer  is  fortunate  if  his  board  of 
health  will  give  sympathetic  consideration  to  his  plans  for  con- 
structive health  work,  or  if  members  of  the  board  will  accompany 
him  on  investigations  of  difficult  conditions. 

Relations  of  a  Local  Board  to  a  State  Department  of  Health. 
— The  laws  under  which  health  boards  are  established  often 
charge  both  the  State  Department  of  Health  and  the  local  health 
boards  jointly  with  the  enforcement  of  the  laws.  For  example, 
Section  4  of  the  New  York  State  PubHc  Health  Law  reads  that 
the  State  Commissioner  of  Health  "shall  be  charged  with  the 
enforcement  of  the  public  health  law  and  the  sanitary  code"; 
and  Section  21b  reads  that  the  health  officers  "shall  within  their 
jurisdiction  enforce  the  provisions  of  the  public  health  law  and 
sanitary  code."  The  universal  intent  is  that  the  State  Depart- 
ment of  Health  shall  assume  command  when  actual  danger  is 
at  hand,  and  at  other  times  shall  act  as  a  kindly  teacher  and 
counselor  to  the  local  health  authorities.  For  example,  a  state 
department  of  health  will  examine  a  public  water-supply,  and  if 


THE  LOCAL  BOARD  OF  HEALTH  37 

the  water  is  not  pure,  it  will  point  out  the  sources  of  pollution 
and  will  advise  the  local  authorities  regarding  remedial  meas- 
ures; but  if  the  pollution  produces  sickness,  the  State  Depart- 
ment of  Health  may  take  charge  of  the  situation  and  compel  the 
local  authorities  to  remedy  the  conditions. 

Local  health  boards  sometimes  resent  the  participation  of  a 
state  department  of  health  in  local  affairs,  and  they  support  their 
attitude  with  variations  of  three  stock  arguments:  first,  that  the 
public  will  be  alarmed;  second,  that  the  town  is  the  healthiest 
spot  in  the  country;  third,  that  the  methods  of  investigation  are 
mysterious  and  impractical. 

A  town  is  always  in  danger  from  fire,  but  the  people  take 
pride  in  their  elaborate  pieces  of  fire-fighting  apparatus.  The 
fire  companies  usually  secure  the  equipment  by  means  of  an 
active  campaign  in  which  they  point  out  the  danger  to  the 
village  if  the  best  means  of  fighting  fire  are  not  obtained.  Call- 
ing attention  to  danger  is  the  first  step  in  guarding  against  it. 
Public  sentiment  is  often  indifferent  to  sanitary  conditions  in  the 
absence  of  an  epidemic,  but  on  the  appearance  of  a  pestilence  it 
goes  to  the  opposite  extreme  of  a  panicky  fear  and  of  a  wild  ex- 
aggeration of  the  sickness  and  danger.  The  best  cure  for  fear 
and  alarm  is  pubHcity  and  education.  When  rural  departments 
of  health  give  as  much  publicity  to  their  activities  as  the  city  and 
state  departments  do,  the  people  will  learn  to  place  a  calm  reli- 
ance on  the  protectors  of  their  health,  and  will  welcome  the 
presence  of  the  experts  from  the  State  Department. 

The  argument  that  a  locality  is  the  healthiest  in  the  land  is 
based  on  the  old  behef  that  the  germs  of  sickness  exist  naturally 
in  the  soil,  air,  and  water.  The  fact  is  that  with  very  few  ex- 
ceptions of  unusual  diseases  the  soil,  air,  and  water  are  free  from 
the  germs  of  human  diseases  unless  they  are  polluted  by  human 
beings.  The  source  of  sickness  is  not  a  locaHty,  but  the  people 
in  it.  The  more  rapid  the  growth  of  a  town  and  the  more  pros- 
perous and  progressive  its  people,  the  greater  is  the  probability 
that  the  citizens  will  come  in  contact  with  persons  who  harbor 
disease  germs.  Popular  health  resorts  are  especially  likely  to 
contain  persons  who  are  mildly  sick  with  unrecognized  infec- 
tious diseases.  The  detection  and  control  of  unsuspected  car- 
riers of  disease  often  require  greater  expert  facilities  than  a 
town  or  village  can  command.  The  aim  of  a  state  department 
of  health  is  to  perfect  and  unify  the  work  by  assuming  the  di- 
rection and  supervision  of  it,  but  leaving  its  execution  as  much 
as  possible  to  the  local  authorities. 

The  first  advances  in  public  health  were  made  through  per- 
sonal and  pubHc  cleanliness.     The  lesson  was  so  well  learned  a 


38  THE   HEALTH    OFFICER 

generation  ago  that  the  people  now  consider  uncleanliness  to  be 
indecency.  They  approve  of  stringent  measures  to  abate  nuis- 
ances which  offend  the  senses,  and  consider  that  the  chief  quaUti- 
cation  of  a  health  officer  is  that  he  shall  have  a  sensitive  nose. 
But  all  have  not  yet  learned  that  the  essential  thing  which  makes 
dirt  dangerous  is  disease  germs  whose  source  is  human  beings, 
ajid  which  are  often  found  in  the  mouths  of  clean  persons,  in 
clear,  tasteless  water,  and  in  appetizing  food.  The  delicacy  and 
refinements  of  the  methods  of  detecting  disease  germs  are  in- 
comprehensible to  those  who  have  never  seen  a  microscope,  and 
the  accuracy  of  their  results  may  seem  uncanny  and  unworthy 
of  belief.  The  tendency  of  the  pubHc  is  to  condemn  what  it 
does  not  understand.  The  truth  is  that  the  detection  of  small 
numbers  of  disease  germs,  and  also  of  intestinal  bacteria,  is  a 
simple  and  easy  problem,  and  is  the  most  practical  and  useful 
procedure  at  the  service  of  a  modern  sanitarian.  Every  health 
department  is  dependent  on  refined  bacteriologic  and  chemical 
examinations  which  few  practising  physicians  know  how  to 
perform.  A  rural  board  of  health  is  dependent  on  outside  as- 
sistance in  tracing  the  origin  of  most  cases  of  communicable 
diseases. 

A  rural  board  of  health  is  usually  wilHng  to  have  the  state 
remedy  unhealthful  conditions  so  long  as  the  local  board  itself 
is  not  required  to  act.  It  is  a  universal  principle  in  American 
government  that  each  community  shall  manage  its  own  affairs 
and  that  each  citizen  shall  bear  his  share  of  the  burden.  The 
responsibiUty  for  public  health  conditions  lies  jointly  with  the 
local  authorities  and  with  the  State  Department  of  Health. 
The  local  health  authorities  are  properly  required  to  suppress 
local  nuisances  that  affect  hfe  or  health,  to  detect  and  control 
ordinary  cases  of  contagious  diseases,  and  to  maintain  sanitary 
inspections  of  dairies,  water-suppHes,  and  sewers.  The  State 
Department  will  supplement  this  work  along  at  least  four 
lines : 

1.  Laboratories  are  maintained  for  the  detection  of  disease 
germs  in  specimens  sent  to  them  by  the  local  health  officers. 
This  service  is  of  the  greatest  importance,  and  its  field  of  use- 
fulness is  constantly  being  extended. 

2.  Antitoxins  and  serums  are  manufactured  and  distributed 
without  cost  through  health  officers  to  all  physicians  who  need 
them  in  the  treatment  or  prevention  of  diseases. 

3.  Medical  experts  and  trained  sanitary  engineers  are  sent 
to  advise  the  local  authorities,  when  the  services  of  experts  are 
needed. 

4.  Educational    literature,    lantern    slides,    moving-picture 


THE    LOCAL  BOARD    OF  HEALTH  39 

films,  charts,  exhibits,  and  lecturers  are  sent  out  to  educate  the 
people  in  public  health  matters. 

Local  boards  of  health  are  likely  to  concern  themselves  prin- 
cipally with  curative  measures,  while  state  departments  of 
health  are  placing  more  and  more  emphasis  on  prevention. 
Efficient  health  officers  and  the  officials  of  state  departments  of 
health  are  doctors  of  the  body  politic,  and  are  trained  to  recog- 
nize unhealthful  conditions  while  they  are  yet  in  the  preventable 
stage.  But  the  pubhc,  like  a  spoiled  child,  does  not  like  to  be 
examined  by  a  doctor,  or  to  submit  to  minor  operations,  or  to 
take  unpleasant  medicine.  When  the  officials  delve  into  sani- 
tary matters,  a  community  often  complains  that  it  is  hurt,  or 
that  it  does  not  want  to  be  bothered,  or  that  it  prefers  the  dis- 
ease to  the  medicine.  Local  boards  of  health  are  often  incapable 
of  treating  themselves.  A  diagnosis  must  usually  be  made  and 
treatment  suggested  by  the  experts  in  the  State  Department  of 
Health,  and  then  frequently  nothing  is  done  unless  the  State 
Department  gently  but  firmly  insists  that  the  public  shall  begin 
treatment. 

Basis  of  Action. — The  source  of  the  power  of  a  board  of  health 
is  the  written  or  statute  law  of  a  state.  Under  it  a  local  board  of 
health  performs  three  classes  of  duties.  The  first  class  of  duties 
consists  of  those  which  are  imposed  on  it  specifically.  These 
relate  largely  to  organization  and  finance.  They' also  include  the 
suppression  of  contagious  diseases  and  the  abatement  of  nuisances, 
but  these  duties  are  usually  performed  by  the  health  officer  as 
the  agent  of  the  board,  and  come  to  the  attention  of  the  board 
itself  only  when  some  one  clearly  violates  the  law.  The  duties 
that  are  specifically  required  of  the  board  are  few,  and  the  board 
that  does  no  more  than  it  has  to  do  is  narrow  in  its  interpretation 
of  the  scope  of  its  work. 

The  second  class  of  duties  consists  of  those  which  a  board  of 
health  is  specifically  permitted  to  perform.  An  example  of  this 
class  of  work  is  that  the  New  York  State  law  permits  a  local 
board  to  employ  a  public  health  nurse.  A  board  that  under- 
takes permissive  work  will  nearly  always  be  supported  by  the 
people.  PubHc  health  work  is  becoming  increasingly  popular,- 
and  the  people  are  beginning  to  demand  that  the  officials  respon- 
sible for  sanitation  shall  give  evidence  that  they  are  doing  some- 
thing more  than  the  specific  routine  duties  that  are  required. 

A  third  class  of  duties  consists  of  those  which  are  not  men- 
tioned in  the  statute  law,  but  which  are  legaHzed  by  a  broad  in- 
terpretation of  a  general  section  of  the  law.  For  example,  the 
New  York  State  law  authorizes  a  health  officer  to  employ  as 
many  assistants  as  may  be  necessary  to  enforce  the  laws,  and  to 


40  THE  HEALTH   OFFICER 

tix  their  compensation  within  the  limits  of  an  appropriation  for 
that  purpose.  This  section  enables  a  board  to  employ  lecturers, 
milk  inspectors,  and  public  vaccinators,  and  to  pubhsh  educa- 
tional literature.  Progressive  boards  of  health  are  constantly 
enlarging  the  scope  of  their  work  by  instituting  new  activities, 
and  by  assuming  charge  of  lines  of  work  wliich  have  been  started 
and  carried  on  by  lay  societies  (see  p.  29). 

Appointment  of  a  Health  Officer. — A  board  of  health  is 
usually  charged  with  the  duty  of  appointing  a  health  officer. 
This  is  the  most  important  duty  that  the  board  has  to  perform, 
for  the  health  officer  is  the  manager  of  the  local  public  health  sys- 
tem, and  is  responsible  for  public  health  conditions  in  his  juris- 
diction. A  doctor  is  not  qualified  to  be  a  health  officer  simply 
because  he  is  successful  in  private  practice.  Yet  some  boards 
advocate  the  appointment  of  a  young  physician  just  starting  into 
practice,  thinking  that  he  will  be  impartial  and  that  his  knowl- 
edge is  of  an  up-to-date  brand;  others  would  choose  a  doctor  who 
is  gruff  and  outspoken  in  manner,  expecting  that  he  will  be  fear- 
less in  the  performance  of  his  duties;  and  some  hand  out  the 
office  as  a  political  reward.  The  position  of  health  officer  is  too 
important  to  be  given  to  any  one  except  to  a  specialist  in  public 
health  who  has  qualified  himself  by  study  and  experience.  New 
York  State  very  properly  requires  that  each  health  officer  shall 
have  made  special  preparation  for  the  office  by  taking  a  course  of 
study  in  public  health. 

Finances. — A  board  of  health  is  charged  by  law  with  the  ex- 
penditure of  public  funds  with  which  public  health  work  is  car- 
ried on.  Finances  are  the  basis  of  all  governmental  activities, 
and  a  board  of  health  can  promote  or  cripple  sanitary  work  by  its 
attitude  toward  expenses.  PubHc  health  work  is  usually  con- 
ducted more  economically  than  any  other  branch  of  the  govern- 
ment's activity,  and  refusals  to  appropriate  money  on  the  grounds 
of  past  extravagance  are  seldom  justified. 

There  are  three  methods  of  making  appropriations  for  public 
health  work.  One  plan  is  to  give  no  money  to  the  board,  but  to 
audit  the  itemized  bills  after  the  work  has  been  done.  This  plan 
has  been  unsatisfactory,  for  financial  boards  often  have  difficulty 
in  seeing  the  justification  of  expenditures  for  guarding  against 
epidemics  which  merely  threaten  a  community  afar  off,  but 
which  never  appear.  A  danger  which  seems  urgent  to  a  board  of 
health  often  becomes  a  vague  memory  when  the  bills  are  audited 
months  afterward  by  a  financial  board  that  knows  nothing  of  the 
real  conditions. 

Another  and  better  plan  is  to  give  the  board  of  health  a  definite 
sum  to  carry  on  ordinary  routine  work  during  the  fiscal  year. 


THE  LOCAL  BOARD  OF  HEALTH  41 

If  the  board  knows  how  much  money  it  will  have  to  spend,  it  can 
plan  its  work  with  confidence  and  intelligence,  and  with  a  view 
to  efficiency  and  economy. 

The  New  York  State  law  provides  a  third  and  still  better  plan 
by  making  the  board  of  health  of  a  village  or  town  to  consist  of 
the  financial  board.  Thus  the  same  body  that  expends  money 
has  the  power  to  raise  it. 

The  budget  of  the  board  of  health  of  a  village  or  town  must 
contain  several  items  which  are  required  by  the  statute  law  of 
most  states.     Among  them  are  the  following: 

1.  The  pay  of  the  health  officer.  The  New  York  State  law 
requires  that  the  pay  shall  be  at  least  10  cents  for  each  inhabitant 
in  his  jurisdiction  up  to  a  population  of  8000.  One  good  effect 
of  this  law  has  been  to  do  away  with  the  practice  of  shopping  for 
a  health  officer  and  of  giving  the  position  to  the  doctor  who  bids 
the  lowest.  It  is  a  principle  of  law  that  an  officer  is  entitled  to 
his  expenses  which  are  necessarily  incurred  in  the  discharge  of 
his  duties,  including  postage,  stationery,  and  traveling  expenses. 

2.  The  pay  of  the  registrar  of  vital  statistics  and  the  fees  to 
physicians  for  reporting  births,  deaths,  and  communicable  dis- 
eases. 

3.  The  maintenance  of  guards  at  quarantined  houses  and  of 
disinfecting  after  communicable  diseases.  The  newer  methods 
of  quarantine  and  of  disinfection  have  greatly  reduced  the  ex- 
penditures for  these  purposes. 

4.  Vaccines,  antitoxins,  culture-tubes,  and  other  suppHes  for 
diagnosis  and  treatment.  State  departments  of  health  are  pre- 
paring more  and  more  of  the  supplies,  and  are  furnishing  them 
free  or  at  cost. 

5.  The  suppression  of  nuisances.  Most  of  the  expenditures 
under  this  head  are  for  legal  services  and  advice. 

6.  Extraordinary  expenditures  such  as  those  incurred  in 
suppressing  epidemics. 

A  board  of  health  may  also  spend  money  for  purposes  which 
are  not  specifically  stated  in  the  statute  law.  The  following  are 
some  of  the  activities  for  which  rural  boards  of  health  often  con- 
tract bills: 

1.  Regular  sanitary  inspections  for  the  discovery  and  sup- 
pression of  nuisances. 

2.  Milk  and  dairy  inspections. 

3.  Public  health  nursing. 

4.  Educational  work,  including  the  expenses  of  lectures  and 
exhibits,  and  of  the  printing  and  distribution  of  educational  Hter- 
ature. 

There  is  no  standard  of  the  amount  of  the  expenses  of  a  rural 


42  THE   HEALTH    OFFICER 

board  of  health.  The  principal  item  will  be  the  health  officer's 
pay,  which  in  New  York  State  must  be  at  least  10  cents  per  capita 
annually.  The  amount  of  the  other  expenses  will  be  at  least  half 
that  of  the  health  officer.  But  clTective  public  health  work  can- 
not be  done  for  15  cents  per  capita.  At  least  twice  that  amount 
is  needed.  New  York  City  spends  70  cents  per  capita  on  its 
local  pubhc  health  work. 

Communicable  Diseases. — A  local  board  of  health  is  charged 
with  the  duly  of  preventing  and  suppressing  communicable  dis- 
eases. The  health  officer  will  attend  to  the  routine  cases  without 
referring  them  to  the  board  of  health.  Yet  the  board  of  health 
will  decide,  either  intentionally  or  unconsciously,  many  matters 
of  great  and  immediate  efTect  in  the  suppression  of  diseases. 
One  matter  of  great  importance  is  the  attitude  of  the  board 
toward  bills  for  the  health  officer's  supplies,  such  as  sputum  cups, 
antiseptics,  and  surgical  dressings.  The  board  will  decide 
whether  disinfections  after  contagious  diseases  shall  be  done  at 
pubhc  expense  or  be  charged  to  the  head  of  the  afflicted  family. 
The  board  will  also  determine  whether  or  not  the  health  officer 
will  feel  free  to  secure  the  services  of  skilled  assistants  to  do  ex- 
pert emergency  work,  such  as  intraspinal  injections  in  lockjaw 
and  intubations  in  croup.  Every  board  of  health  must  neces- 
sarily acquire  a  reputation  among  public  health  workers  for  its 
attitude  either  of  liberality  or  of  parsimony  in  its  expenditures 
for  suppressing  contagious  diseases.  If  it  is  liberal,  a  health 
officer  will  feel  free  to  take  immediate  and  elTective  steps  for 
suppressing  diseases  before  they  get  beyond  control. 

Local  Ordinances. — Local  health  work  is  done  under  the 
authority  of  three  sets  of  laws  or  regulations:  first,  the  statute  law 
which  is  enacted  by  the  legislature;  second,  the  state  sanitary 
code,  if  the  state  department  of  health  has  enacted  one,  as  has 
been  done  in  New  York  State;  third,  local  ordinances  which  are 
enacted  by  the  local  boards  of  health.  Local  ordinances  are  in- 
tended to  specify  the  details  of  matters  which  are  mentioned 
generally  in  the  statute  law.  For  example,  a  statute  law  may 
require  that  every  business  shall  be  conducted  with  due  regard 
to  the  health  and  comfort  of  the  people  of  a  community.  A 
local  board  of  health  may  enact  an  ordinance  applying  this  law 
to  the  livery  men  in  a  village  by  requiring  every  person  who 
keeps  a  horse  to  provide  a  water-tight  and  fly-proof  box  in  which 
all  the  manure  shall  be  kept. 

Local  ordinances  reflect  the  sentiment  of  a  community  toward 
conditions  which  affect  the  health  and  comfort  of  its  inhabitants. 
They  express  the  standards  of  sanitation  in  that  community. 
They  put  the  people  on  their  guard,  and  render  easy  the  detec- 


THE  LOCAL  BOARD  OF  HEALTH  43 

tion  and  conviction  of  offenders.  They  substitute  dcfmiteness  for 
uncertainty  in  the  interpretation  of  laws,  and  supj)ort  the  health 
officer  with  the  authoritative  backing  of  the  representative  body 
of  men  who  made  the  code.  The  enactment  of  a  sanitary  code  is 
a  duty  as  well  as  a  privilege  of  every  local  board  of  health. 

Among  the  subjects  which  may  properly  be  included  in  a 
sanitary  code  are  the  following: 

Communicable  diseases. 

General  relations  of  the  health  officer  to  the  board  of  health. 

Unnecessary  noises. 

Smoke. 

Dogs  in  public  places. 

Food  inspections. 

Dairy  regulations. 

Garbage  disposal. 

Slaughter  houses. 

Disposal  of  household  wastes. 

Cesspool  construction  and  cleaning. 

Privy  construction  and  management. 

Pig-pens  and  chicken  yards. 

Disposal  of  stable  manure.  ' 

Prevention  of  the  breeding  of  flies  and  mosquitoes.  ■ 

Housing  rules.  • 

Street  cleaning. 

Legal  Matters. — The  handling  of  all  legal  matters  is  one  of 
the  duties  of  a  local  board  of  health.  The  abatement  of  nui- 
sances and  the  suppression  of  unhealthful  conditions  rests  with 
the  health  officer;  but  if  he  is  unable  to  secure  a  remedy  by 
personal  appeals  to  the  offenders,  the  next  step  is  to  ask  the  aid 
of  the  police  or  of  the  law  courts.  The  judgment  whether  or  not 
legal  action  is  required  rests  with  the  board  of  health  after  hear- 
ing the  medical  and  scientific  evidence  given  by  the  health  officer. 
The  board  of  health  can  act  in  an  emergency  through  a  standing 
committee,  or  through  one  of  its  members.  Legal  action  is  too 
serious  a  procedure  to  be  started  by  a  health  officer  without  the 
advice  or  orders  of  his  official  superiors.  It  is  the  dut}-  of  every 
member  of  a  board  of  health  to  give  immediate  attention  to  the 
requests  of  a  health  officer  for  legal  advice  and  assistance.  The 
fact  that  the  health  officer  is  acting  under  orders  of  a  member  of 
the  board  of  health  will  often  bring  an  offender  to  terms.  If  it  is 
necessary  for  a  health  officer  to  have  the  aid  of  the  police  or  the 
law  courts,  his  board  of  health  owes  him  the  protection  of  au- 
thorizing him  to  employ  that  assistance.  Health  officers  are 
frequently  sued  personally  for  assuming  to  do  necessary  acts  in 
which  boards  of  health  have  not  been  consulted.    The  responsi- 


44  THE   HEALTH    OFFICER 

bility  for  action  or  inaction  in  any  given  case  that  is  brought 
to  their  attention  rests  equally  with  the  health  officer  and  the 
board  of  health.  The  New  York  State  sanitary  code  charges 
boards  of.  health  with  the  responsibihty  of  taking  the  necessary 
steps  to  abate  nuisances  which  health  officers  are  unable  to  abate 
by  ordinary  means. 

Reports. — It  is  the  duty  of  a  board  of  health  to  demand  re- 
ports from  its  health  officer,  and  to  consider  them  seriously,  in 
order  to  know  what  is  taking  place  in  its  jurisdiction.  It  is  often 
the  attitude  of  a  board  of  health  to  consider  the  health  officer's 
reports  to  be  either  a  bore  or  a  joke.  A  health  officer  whose  re- 
ports are  treated  lightly  has  no  incentive  to  do  good  work.  If 
his  board  of  health  shows  no  interest  in  public  health  work,  much 
less  can  the  general  public  be  expected  to  appreciate  it.  If  a 
health  officer  is  failing  to  earn  his  salary,  the  board  of  health  is 
equally  responsible  with  him,  for  the  board  is  supposed  to  be 
familiar  with  his  work. 

A  monthly  report  on  all  the  varied  activities  of  a  health  officer 
will  enable  the  board  of  health  to  compare  them  with  the  past 
and  to  form  plans  and  estimates  for  future  work.  It  will  en- 
courage the  health  officer  to  have  something  worthy  to  report 
and  will  educate  the  public  regarding  the  scope  and  importance 
of  the  sanitary  work  in  a  community.  The  New  York  State 
Department  of  Health  requires  a  monthly  report  from  every 
health  officer. 

Relation  of  a  Board  of  Health  to  the  Public. — The  public 
expects  a  local  board  of  health  to  protect  the  citizens  from  pre- 
ventable diseases  and  deaths,  to  understand  the  problems  of 
sanitation  and  public  health  in  its  jurisdiction,  and  to  take  the 
lead  in  promoting  the  health  of  all  persons  in  the  community. 
The  work  of  a  department  of  health  is  based  on  education  and 
expert  knowledge  which  is  often  unappreciated  by  the  general 
public.  If  the  appropriations  for  public  health  work  depended 
on  the  votes  of  a  majority  of  the  taxpayers,  very  little  work 
would  be  done  except  to  fight  fully  developed  epidemics.  The 
very  success  of  public  health  work  in  preventing  diseases  blinds 
people  to  the  need  that  the  work  be  continued,  and  even  pushed 
with  increased  \dgor.  A  board  of  health  is  expected  to  lead  the 
public  in  the  movement  for  a  still  broader  field  of  health  work 
and  for  more  eft'ective  steps  in  the  prevention  of  disease  and  in 
the  prolongation  of  lives. 


CHAPTER  IV 
THE   PUBLIC    AND    THE    HEALTH    OFFICER 

"Public  Health  is  Purchasable"  is  the  motto  of  the  Depart- 
ment of  Health  of  New  York  State.  Every  health  officer  is  an 
agent  who  offers  pubhc  health  for  sale.  The  people  generally 
think  that  pubhc  health  is  a  good  thing  to  have,  but  some- 
times they  expect  to  get  it  free,  like  their  air  and  rain,  and  are 
unwilling  to  pay  money  for  it  or  to  get  it  by  work.  They  usually 
judge  the  value  of  public  health  by  a  few  samples  of  work  which 
they  see  done  by  amateur  health  officers;  but  they  are  usually 
wilhng  to  pay  taxes  in  support  of  public  health  work  whenever 
they  see  its  value  demonstrated  by  actual  trial  in  their  midst. 
A  health  officer  has  the  power  to  correct  many  of  the  popular 
misapprehensions  regarding  the  aims  and  scope  of  his  work. 

Public  health  work  was  formerly  spectacular.  It  dealt  with 
wide-spread  epidemics  while  the  people  were  in  panics  of  fear 
and  were  ready  to  adopt  any  measure  that  offered  a  hope  of 
relief.  It  consisted  in  cleaning  great  collections  of  filth  from  the 
streets,  in  bringing  supplies  of  pure  water  into  cities,  and  in 
constructing  extensive  sewer  systems.  Such  work  as  this  al- 
most eradicated  cholera  from  the  United  States,  and  has  reduced 
typhoid  fever  to  a  tenth  of  its  former  prevalence.  Its  striking 
results  gave  people  the  idea  that  the  complete  eradication  of  visi- 
ble dirt  would  cut  down  all  infectious  diseases,  but  it  had  little 
or  no  effect  on  diphtheria,  scarlet  fever,  and  pneumonia.  It  is 
probable  that  this  line  of  work  has  nearly  reached  its  full  develop- 
ment, for  we  have  already  controlled  the  diseases  that  are  spread 
by  gross  filth.  Civilized  people  now  generally  observe  private 
and  municipal  cleanliness  to  a  degree  that  was  advocated  by 
only  a  few  of  the  leading  sanitarians  a  couple  of  generations  ago. 
Their  advanced  ideas  are  now  habitually  practised  by  most 
people,  and  we  are  surprised  when  we  find  a  community  that 
has  not  reached  that  standard  of  cleanliness  and  of  what  we 
call  decency.  For  example,  we  expect  every  dwelHng  to  be  pro- 
vided with  some  kind  of  a  toilet  arrangement,  and  we  are 
shocked  to  learn  that  hookworm  disease  is  prevalent  in  some 
sections  of  the  United  States  because  of  the  lack  of  such  facilities. 
A  health  officer  now  has  to  clean  up  only  an  occasional  house 
or  yard,  ior  pubhc  sentiment  demands  that  every  house  and 
yard  shall  be  kept  clean,  and  that  all  sewage  and  garbage  shall 

45 


46  THE    HEALTH    OFFICER 

be  removed  from  sight.  There  is  a  great  outcry  if  a  health 
officer  fails  to  compel  the  observance  of  this  standard  of  clean- 
liness by  the  few  who  do  not  observe  it.  IMost  persons  have  an 
unreasonable  fear  of  what  is  offensive  to  their  sight  and  smell, 
and  when  an  infectious  disease  breaks  out,  they  can  readily 
find  an  infraction  of  the  standards  of  cleanliness  to  wliich  they 
can  ascribe  it.  But  filth  is  not  often  the  cause  of  the  common 
epidemics  that  now  prevail  among  intelligent  people.  The 
trained  health  officer  no  longer  expects  to  find  the  cause  of  a 
sickness  in  things.  He  looks  for  it  in  persons.  He  knows  that 
unclean  tilings  do  not  produce  diseases  unless  the  dirt  comes 
from  persons  who  are  producing  disease  germs  in  their  bodies. 
But  the  germs  of  which  he  talks  are  invisible  and  sometimes 
they  do  not  produce  evident  sickness  in  the  persons  in  whom 
they  grow.  Most  people  do  not  yet  understand  why  a  health 
officer  should  pay  Kttle  attention  to  back  yards,  and  yet  should 
restrain  the  liberty  of  an  apparently  well  boy  whom  he  accuses 
of  carrying  diphtheria  germs  in  his  throat.  It  seems  to  them 
that  the  health  officer  talks  about  danger  when  there  is  none, 
and  that  he  is  a  false  prophet  who  magnifies  dangers  and  arouses 
fears  unnecessarily.  A  common  argument  for  instituting  and 
enlarging  public  health  work  is  that  there  will  be  a  sickness  if 
existing  conditions  are  allowed  to  go  on.  It  usually  happens 
that  few  persons  get  sick,  and  that  epidemics  are  rare,  and  so 
the  health  officer  is  discredited,  together  with  his  allies  and 
supporters.  A  community  is  usually  slow  to  take  warning  from 
the  experiences  of  a  village  ten  miles  away,  and  its  people  are 
usually  convinced  only  by  a  disastrous  epidemic  in  their  own 
midst.  Public  health  work  is  so  new  and  modern  that  a  knowl- 
edge of  its  basis  and  scope  has  not  yet  become  common.  It 
takes  about  a  generation  for  a  knowledge  of  medical  progress 
to  filter  from  the  leaders  down  through  the  practising  physicians 
and  to  the  great  mass  of  people. 

Health  officers  are  often  impatient  with  what  seem  to  them 
to  be  the  stubbornness  and  hostility  of  the  people,  but  which 
is  really  only  ignorance.  A  health  officer  must  always  deal  with 
ignorant  people,  for  he  is  hopelessly  behind  the  times  if  the  peo- 
ple whom  he  serves  know  as  much  as  he.  Whether  or  not  a 
health  officer  meets  with  stubbornness  and  hostility  will  de- 
pend largely  on  his  own  attitude  toward  his  people.  Most 
stubbornness  is  merely  indifference  due  to  ignorance;  and  hos- 
tility is  usually  due  to  a  health  officer's  disregard  of  the  peo- 
ple's feelings.  A  health  officer  can  usually  control  the  attitude 
of  the  people  toward  him.  The  methods  which  he  can  em- 
ploy effectively  are  those  of  education  and  example. 


THE   PUBLIC   AND    THE   HEALTH    OFFICER  47 

A  health  officer  can  educate  his  people  by  taking  pains  to 
explain  what  he  wants  done  in  each  case,  and  the  reasons  for 
doing  it.  Each  visit  and  inspection  affords  him  an  opportunity 
to  instruct  a  number  of  persons,  and  they  will  pass  the  advice 
to  others  until  the  whole  community  will  know  what  to  expect 
from  a  health  officer.  The  object  of  his  talk  is  to  make  people 
really  understand  what  he  is  talking  about.  If  he  uses  tech- 
nical language,  the  people  will  not  understand  him,  but  they 
will  think  that  the  work  which  he  is  trying  to  do  is  a  technical 
matter  which  they  cannot  understand,  and  with  which,  there- 
fore, a  common  person  has  nothing  to  do.  But  if  a  health  officer 
uses  the  every-day  language  and  expressions  of  the  home,  his 
ideas  will  fit  into  the  usual  lines  of  thought  of  his  hearers,  and 
will  become  a  real  part  of  their  common  thought.  The  most 
effective  of  all  means  of  educating  the  public  in  health  work  is 
by  brief  explanations  by  the  health  officer  during  his  ordinary 
calls. 

The  feelings  of  the  people  toward  a  health  officer  and  his 
work  will  depend  largely  on  the  feelings  which  the  people  think 
the  health  officer  has  toward  them.  If  the  health  officer  is 
gruff  and  overbearing  and  issues  threats  and  curt  orders,  the 
people  will  naturally  have  little  use  for  him  or  his  work.  When 
ignorant;  inefficient  persons  wish  to  make  themselves  impres- 
sive, they  talk  loudly,  make  threats  they  are  powerless  to  carry 
out,  and  use  exaggerated  language  which  no  one  believes.  If  a 
health  officer  does  these  things,  he  is  like  an  engine  that  is  out 
of  order  and  is  producing  more  noise  than  work.  He  seems  to 
be  neglecting  the  health  conditions  which  he  is  investiagting, 
aM  to  be  seeking  personal  quarrels  with  those  to  whom  he  is 
talking.  An  efficient  health  officer  will  confine  himself  with  a 
singleness  of  purpose  to  the  matter  which  he  is  investigating 
and  will  not  be  sidetracked  by  personalities.  He  will  try  to 
leave  a  person  in  such  a  state  of  mind  that  he  is  thinking  only 
of  remedying  an  unsanitary  condition  while  forgetting  the 
health  officer.  The  best  personal  assets  for  a  health  officer  in 
dealing  with  people  are  a  listening  ear,  an  unhurried  manner, 
a  quiet  tone  of  voice,  and  the  use  of  temperate  language  which 
means  exactly  what  it  says. 

Some  persons  consider  a  health  officer  to  be  a  trouble  maker 
and  an  enemy.  The  public  will  be  likely  to  hold  this  opinion 
if  the  health  officer  does  only  police  duty  and  confines  his  work 
to  repressive  measures,  such  as  giving  spasmodic  and  erratic 
orders  on  the  receipt  of  complaints,  and  enforcing  harsh  quar- 
antines when  contagious  diseases  are  reported.  The  public  will 
look  upon  a  health  officer  as  a  friend  when  he  does  constructive 


48  THE   HEALTH   OFFICER 

work,  such  as  assisting  in  the  treatment  of  contagious  diseases 
and  promoting  child  welfare  work. 

The  people  sometimes  consider  a  health  ofhcer  to  be  an 
impractical  theorist  and  his  work  a  joke.  They  get  this  notion 
when  they  see  health  officers  advocating  impossible  reforms  and 
impracticable  measures,  such  as  the  ventilation  of  every  public 
building,  or  the  use  of  a  nasal  douche  by  every  child  as  a  pre- 
ventive against  contagious  diseases.  Every  active  health  ofhcer 
has  advanced  ideas  which  seem  impossible  to  carry  out.  Prog- 
ress depends  on  giving  publicity  to  these  ideas  and  in  securing 
their  adoption.  A  health  officer  will  retain  the  respect  and 
support  of  the  public  if  he  consults  the  physicians  of  his  town  and 
brings  his  ideas  before  the  people  for  discussion  before  he  tries 
to  force  them  upon  the  community. 

While  people  are  slow  to  take  warning  when  danger  is  in- 
visible, they  often  go  into  a  panic  in  the  presence  of  an  epi- 
demic, and  demand  that  the  health  officer  shall  go  the  limit  in 
the  use  of  discredited  methods  of  suppression,  such  as  closing 
schools  and  restricting  tra\'el.  A  panic  is  the  result  of  ignor- 
ance and  uncertainty.  If  a  health  department  is  secretive  and 
undecided,  the  people  will  become  alarmed  and  will  demand 
unreasonable  actions.  A  policy  of  publicity  and  education 
regarding  the  cause  and  progress  of  the  epidemic  and  the  means 
of  its  suppression  will  reassure  the  people  and  secure  their 
support. 

The  people  of  a  community  sometimes  think  that  a  health 
officer  has  an  easy  job,  and  so  they  are  willing  that  the  office 
should  be  given  as  a  rew^ard  for  political  work.  If  the  health 
activities  in  a  community  are  confined  to  police  work  which  a 
constable  can  do,  the  people  are  justified  in  their  low  opinion 
of  the  office.  But  every  health  officer  is  subject  to  inconveni- 
ences and  dangers  which  are  peculiar  to  the  office.  When  he 
comes  from  a  case  of  contagious  disease,  many  persons  refuse 
to  employ  him  as  their  physician  for  fear  that  he  will  carry  dis- 
ease germs.  A  health  officer  usually  loses  more  money  from  his 
well-to-do  patients  than  he  gets  from  his  salary. 

A  health  officer  is  also  in  danger  of  catching  contagious  dis- 
eases from  the  cases  which  he  visits.  For  example,  he  must 
examine  the  throats  of  children  who  have  diphtheria  and  scarlet 
fever,  and  run  the  risk  that  they  will  cough  disease  germs  into 
his  face.  Most  people  have  a  horror  of  contagious  diseases, 
and  yet  they  do  not  give  the  health  officer  credit  for  his  dis- 
regard of  the  danger  to  which  he  is  subjected. 

People  in  rural  districts  hardly  know  what  kind  or  quantity 
of  health  work  to  demand  from  their  health  officer,  or  how  much 


THE   PUBLIC   AND   THE   HEALTH   OFFICER  49 

to  pay  him  for  it.  The  health  officer  can  enhghten  them  if  he 
keeps  a  record  of  his  work  and  the  time  spent  in  doing  it.  The 
laws  of  New  York  State  require  that  a  health  officer  shall  be 
paid  at  least  10  cents  for  each  inhabitant  of  his  district.  Hun- 
dreds of  health  officers  receive  less  than  $200  annually.  The 
people  know  that  this  sum  will  not  purchase  much  public  health 
work.  A  good  health  officer  is  public  spirited,  and  will  do 
excellent  work  regardless  of  what  his  salary  is.  The  people 
will  usually  grant  him  adequate  pay  when  his  reports  show  that 
it  is  justified.  A  health  officer  can  profit  by  a  study  of  the  ad- 
vertising methods  of  merchants  and  manufacturers.  The  first 
step  is  to  do  good  work,  and  the  second  is  to  make  his  work  known 
by  reports,  lectures,  and  articles  in  the  local  newspapers.  This 
is  legitimate  advertising,  for  it  promotes  public  health  work  and 
makes  it  known  to  the  public. 

Whenever  an  epidemic  breaks  out,  the  streets  are  full  of 
exaggerated  rumors  regarding  the  number  and  severity  of  the 
cases  and  the  laxity  of  the  suppressive  measures.  These  rumors 
interfere  seriously  with  health  administration,  and  cause  the 
health  officer  much  inconvenience  and  annoyance.  Those  who 
hear  the  gossip  can  do  a  great  service  in  the  cause  of  public 
health  by  investigating  the  rumors  and  ascertaining  how  much 
truth  is  in  them  before  they  criticize  the  health  officer. 

The  people  have  much  to  do  with  making  the  work  of  a 
health  officer  a  success.  The  greatest  source  of  his  power  is 
favorable  public  sentiment.  A  state  department  of  health  is 
able  to  enforce  the  public  health  laws  in  larger  matters,  but 
public  health  measures  secured  by  force  are  not  nearly  so  ef- 
fective as  those  which  are  carried  out  voluntarily.  The  prin- 
ciple of  home  rule  prevails  in  public  health  administration  as 
in  other  matters.  One  of  the  best  assets  of  a  community  is  a 
reputation  for  healthf ulness ;  and  this  will  depend  largely  on  the 
attitude  of  the  people  toward  the  health  officer  and  the  depart- 
ment of  health. 


CHAPTER  V 
THE  PHYSICIAN  AND  THE  HEALTH  OFFICER 

Public  Opinion  and  the  Physician. — Every  ph}sician  is  a 
guardian  of  public  health,  and  the  people  expect  him  to  be  in- 
terested in  medical  matters  of  a  public  nature,  just  as  they 
expect  the  lawyer  to  speak  out  regarding  the  legal  aspects  of 
public  affairs,  or  any  other  citizen  to  contribute  his  best  thoughts 
upon  public  questions.  The  opportunities  and  influence  of  the 
physician  as  an  educator  are  greater  than  those  of  almost  any 
other  person.  Nearly  every  person  has  a  blind  and  implicit 
confidence  in  the  word  of  some  physician,  and  the  attitude  of 
the  people  toward  public  health  matters  is  the  composite  atti- 
tude of  the  physicians  of  a  community.  The  knowledge  and 
practice  of  many  physicians  in  matters  of  public  health  is  that 
of  five,  ten,  or  twenty  years  ago,  and  their  ideas  are  adopted  by 
the  people  on  their  visiting  lists.  Few  medical  schools  have  given 
instruction  in  preventive  medicine,  and  almost  the  only  phy- 
sicians who  can  qualify  as  public  health  specialists  are  those 
who  have  been  intensely  public  spirited  and  unselfish,  and  have 
kept  themselves  up  to  date  in  all  lines  of  medical  progress.  But 
medical  schools  are  now  beginning  to  require  courses  in  pubHc 
health,  state  departments  of  health  are  insisting  that  physicians 
shall  know  and  practice  the  most  modern  methods  of  public 
health  procedure,  and  the  people  are  becoming  educated  by 
lectures  and  magazine  articles  to  demand  that  family  physicians 
shall  practice  modern  preventive  medicine.  It  will  be  neces- 
sary that  physicians  in  the  future  shall  take  more  and  more 
interest  in  public  health  affairs. 

The  Attitude  of  the  Physician. — Physicians  are  often  inclined 
to  shirk  public  health  work.  They  say  that  the  people  do  not 
appreciate  the  work  of  a  health  officer;  that  many  persons  re- 
sent interference  with  their  personal  liberties;  that  public  health 
workers  make  enemies;  and  that  the  physician  who  practices 
preventive  medicine  soon  loses  his  private  patients.  Most 
physicians  are  compelled  to  give  their  attention  to  the  work 
that  pays  a  financial  return.  But  a  few  pioneers  have  done 
public  health  work  because  it  needs  to  be  done,  and  by  their 
sacrifices  of  private  gain  they  have  established  preventive 
medicine  as  a  specialty  which  future  physicians  will  probably 
exploit  and  make  profitable.  The  people  are  unwilling  to  pay 
50 


THE   PHYSICIAN   AND    THE   HEALTH    OFFICER  51 

for  public  health  work,  for  they  do  not  sec  the  need  of  it.  Here 
is  an  undeveloped  field  in  medicine.  Let  the  physician  take 
more  interest  in  preventive  medicine  as  a  specialty  and  educate 
the  public  to  desire  it,  and  soon  the  people  will  respond  by  offer- 
ing their  dollars  in  order  to  obtain  its  benefits. 

Some  physicians  consider  that  they  are  under  no  obligation 
to  practice  preventive  medicine.  They  say  that  they  are  paid 
to  treat  sickness  and  not  to  do  a  health  ofiicer's  work  of  placing 
restrictions  upon  a  family.  Those  who  employ  a  physician  have 
a  right  to  expect  that  he  will  advise  them  not  only  how  they 
may  recover  from  sickness  but  also  how  they  may  prevent  the 
sickness  from  developing  again  in  the  future,  and  from  spread- 
ing the  disease  to  other  persons.  The  laws  and  sanitary  code  of 
New  York  State  recognize  these  obligations,  and  require  phy- 
sicians to  perform  specific  duties  which  make  them  an  official 
part  of  the  public  health  organization  of  the  state.  A  number 
of  mandatory  duties  are  imposed  upon  every  physician  by  the 
public  health  law  and  the  state  sanitary  code,  other  duties  are 
implied,  and  an  intimacy  and  co-operation  with  the  health 
organization  are  presupposed.  The  duties  which  are  imposed 
upon  physicians  by  law  in  New  York  State  are  those  which  the 
public  has  a  right  to  expect  all  physicians  everywhere  to  per- 
form. One  of  the  duties  of  a  health  officer  is  to  instruct  phy- 
sicians in  their  duties  to  the  state,  and  to  assist  them  in  per- 
forming those  duties. 

Reporting  Communicable  Diseases. — The  Public  Health  Law 
of  New  York  State  (Sec.  25)  imposes  a  mandatory  duty  upon 
every  physician  that  he  shall  immediately  give  notice  of  every 
case  of  infectious  and  contagious  or  communicable  disease,  re- 
quired by  the  State  Department  of  Health  to  be  reported  to  it, 
to  the  health  officer  of  the  city,  town,  or  village  where  such 
disease  occurs.  The  New  York  State  Sanitary  Code  (Chap.  2, 
Sec.  2)  requires  a  physician  to  make  the  report  within  twenty- 
four  hours  after  he  sees  the  case  for  the  first  time,  and  immedi- 
ately when  the  case  is  on  a  dairy  farm.  Reporting  communi- 
cable diseases  is  universally  conceded  to  be  necessary  in  prevent- 
ing their  spread,  and  a  physician  can  comply  with  the  require- 
ment without  embarrassment  when  the  disease  is  evident  and 
the  diagnosis  is  plain.  But  a  physician  is  often  censured  by 
indignant  citizens  for  making  reports  when  the  classic  signs  of 
the  disease  are  undeveloped  or  the  diagnosis  is  uncertain.  It  is 
the  implied  duty  of  every  physician  to  make  a  correct  diagnosis 
within  a  few  hours  after  he  first  sees  a  case.  He  is  a  diagnos- 
tician for  the  department  of  health  as  well  as  for  the  private 
patient,  and  it  is  his  duty  to  make  prompt  use  of  all  available 


52  THE   HEALTH    OFFICER 

means  of  diagnosis.  It  is  the  privilege,  as  well  as  the  dut}'-,  of 
every  physician  to  avail  himself  of  the  diagnostic  services  of  the 
health  officer  in  every  suspicious  case.  If  the  physician  reports 
a  suspicious  case,  the  health  officer  must  assume  the  further 
responsibility  for  determing  the  diagnosis,  for  making  a  final 
report  on  the  case,  and  for  preventing  the  spread  of  the  disease. 

The  attitude  of  physicians  toward  reporting  cases  depends 
largely  upon  the  health  officer.  If  the  health  officer  is  a  polit- 
ical appointee  with  no  special  qualifications  for  his  work,  phy- 
sicians will  naturally  have  no  confidence  in  him,  and  will  report 
cases  only  on  compulsion.  But  if  the  health  officer  is  known 
to  be  an  expert  in  diagnosing  communicable  diseases,  and  is 
trustworthy,  popular,  and  diplomatic,  the  physicians  will  have 
confidence  in  him  and  will  gladly  consult  him. 

Physicians  are  entitled  to  the  protection  and  support  of  the 
health  officer  in  performing  the  unpleasant  duty  of  giving  the 
pubHc  the  benefit  of  the  doubt  in  suspicious  cases,  and  in  mak- 
ing a  decision  which  involves  the  curtailment  of  the  liberties 
of  patients  and  their  families  when  the  signs  of  disease  are  faint 
and  obscure.  A  physician  is  naturally  unwilling  to  acknowledge 
ignorance  in  diagnosing  common  diseases,  or  to  appear  to  con- 
cede superior  diagnostic  ability  to  another  practitioner  in  his 
own  locality.  The  local  physicians  form  the  first  line  of  defense 
against  communicable  diseases,  and  the  efficiency  of  that  defense 
depends  on  their  alertness  and  willingness  to  co-operate  with  the 
health  authorities.  When  the  health  officer  is  not  obviously  an 
expert  diagnostician,  and  does  not  enjoy  the  full  confidence  of 
his  medical  brethren,  the  physicians  have  a  large  measure  of 
excuse  for  their  hesitation  to  report  cases  on  suspicion.  The 
responsibility  for  the  attitude  does  not  rest  upon  physicians 
alone,  but  it  rests  equally  upon  boards  of  health  that  appoint 
health  officers  of  inferior  ability.  On  the  other  hand,  physicians 
and  their  organizations  have  an  obvious  duty  to  perform  in  ad- 
vising boards  of  health  regarding  the  qualifications  of  pro- 
spective health  officers.  They  know  better  than  any  one  else 
what  are  the  abihties  of  candidates,  and  their  advice  would 
be  invaluable  in  securing  high-grade  men  for  the  office. 

Health  officers  and  other  members  of  departments  of  health 
have  the  unique  distinction  of  forming  almost  the  only  official 
body  that  requires  physicians  to  be  up  to  date  in  their  knowledge 
and  practice,  and  accurate  in  their  diagnoses.  After  a  phy- 
sician obtains  a  license  to  practice  medicine,  there  is  no  law 
that  compels  him  to  continue  his  studies  or  to  make  a  further 
advance  of  his  knowledge.  He  is  allowed  to  practice  the  kind 
of  medicine  which  he  learned  fifty  years  ago  in  nearly  every  line 


THE   PHYSICIAN   AND   THE   HEALTH    OFFICER  53 

except  communicable  diseases;  but  he  cannot  handle  that  class 
of  diseases  unless  he  keeps  himself  fairly  up  to  date  in  knowledge. 
Each  health  officer  is  an  inspector  who  reviews  the  work  of  family 
physicians  in  their  management  of  communicable  diseases,  and 
compels  them  to  study  whether  they  wish  to  do  so  or  not. 
Health  officers  have  a  great  influence  in  promoting  knowledge 
and  efficiency  on  the  part  of  physicians.  An  expert  health  offi- 
cer will  lead  and  inspire  physicians  to  study,  while  one  with 
inferior  abihty  and  a  combative  nature  will  drive  them  to  study 
for  the  protection  of  themselves  and  their  patients  against  the 
unwise  acts  of  the  health  officer. 

Isolation  and  Disinfection. — It  is  a  recognized  duty  of  a 
physician  when  he  treats  a  case  of  communicable  disease  that 
he  advise  the  family  regarding  the  procedures  to  take  in  order 
to  prevent  the  spread  of  the  disease.  The  New  York  State 
Sanitary  Code  (Chap.  2,  Sees.  11,  16,  and  17)  requires  physi- 
cians to  secure  the  isolation  of  cases  of  communicable  disease 
and  the  proper  disinfection  and  disposal  of  the  excreta  and  dis- 
charges from  the  sick.  These  measures  are  to  be  taken  immedi- 
ately on  the  discovery  of  the  case.  Physicians  take  contra- 
dictory views  of  their  duties  and  privileges  regarding  isolation 
and  disinfection.  Some  would  avoid  the  responsibility  and  em- 
barrassment of  imposing  restrictions  upon  their  own  private 
patients,  and  would  place  that  disagreeable  duty  entirely  upon 
the  health  officer.  Others  object  to  visits  of  the  health  officer, 
and  wish  to  attend  to  the  duties  of  isolation  and  disinfection 
themselves.  These  duties  may  be  made  easy  for  both  the 
health  officer  and  the  physician  by  the  adoption  of  uniform  meth- 
ods of  procedure  by  health  departments  and  boards  of  health. 
The  New  York  State  Department  of  Health  issues  circulars  of 
information  for  each  disease,  stating  what  the  parents,  the 
physician,  and  the  health  officer  are  to  do.  Such  a  circular  of 
information  is  an  official  notification  of  the  standard  measures 
which  have  been  devised  by  experts.  It  relieves  the  physician 
of  the  embarrassment  of  seeming  to  originate  the  restrictions, 
and  the  health  officer  from  the  charge  that  his  measures  are 
arbitrary  and  are  imposed  with  partiaKty. 

While  a  physician  is  expected  to  advise  a  family  regarding 
the  proper  measures  of  preventing  the  spread  of  diseases,  the 
enforcement  of  the  measures  upon  unwilling  persons  is  the  duty 
of  the  health  officer.  It  is  the  duty  of  the  physician  to  inform 
the  health  officer  regarding  violations  of  the  preventive  meas- 
ures, and  to  give  him  the  entire  control  of  isolation  and  dis- 
infection when  the  violations  are  repeated  and  serious. 

Instituting   quarantines,   directing   isolations   and   disinfec- 


54  THE    HEALTH    OFFICER 

tions,  and  discharging  cases  of  communicable  diseases  and 
pronouncing  them  free  from  infectiousness  are  all  official  duties 
which  devolve  primarily  upon  the  health  officer,  and  it  would 
seem  proper  to  require  the  health  officer  to  visit  every  case  of 
communicable  disease  in  order  to  advise  regarding  isolation  and 
disinfection,  to  determine  the  time  of  discharge  from  observa- 
tion, and  to  give  a  certificate  of  freedom  from  disease.  The 
ideal  condition  is  that  in  which  the  health  officer  and  the  phy- 
sician work  in  close  co-operation  in  all  these  matters. 

Laboratory  Supplies. — Departments  of  health  of  many  states 
furnish  laboratory  supplies  for  both  diagnosis  and  treatment. 
It  is  the  implied  duty  of  physicians  that  they  make  use  of  the 
supplies.  The  Sanitary  Code  of  New  York  State  (Chap.  2, 
Sec.  10)  requires  physicians  to  take  a  culture  from  every  person 
whom  they  suspect  to  have  diphtheria.  Physicians  have  the 
right  to  expect  the  cordial  assistance  and  co-operation  of  the 
health  officer  in  the  use  of  the  laboratory  material.  The  health 
officer  is  supposed  to  know  how  to  take  cultures  and  specimens 
for  examination,  and  to  be  able  to  administer  antitoxins  and 
vaccines. 

Vaccination. — It  would  seem  that  vaccination  for  the  pre- 
vention of  smallpox  is  a  subject  in  which  the  truth  should  be 
known  and  universally  accepted  by  physicians.  The  causes  of 
the  dangers  and  accidents  that  follow  vaccination  are  well 
known,  and  may  be  readily  prevented.  If  the  instructions  that 
are  sent  out  by  the  departments  of  health  of  the  leading  states 
and  cities  were  followed,  there  would  be  no  complications  follow- 
ing vaccination.  It  is  the  duty  of  every  physician  to  become 
familiar  with  these  instructions. 

Tuberculosis. — The  laws  of  the  several  states  are  imposing 
an  increasing  number  of  duties  upon  physicians,  registrars,  and 
health  officers  for  the  control  of  tuberculosis.  It  is  the  intent 
of  the  laws  to  compel  physicians  to  seek  for  cases  of  the  dis- 
ease instead  of  trying  to  avoid  them.  The  tuberculosis  law  of 
New  York  State  covers  several  pages,  and  its  effect  is  to  make  a 
physician  act  as  an  inspector  for  the  department  of  health  for 
each  case  of  tuberculosis  that  he  treats,  unless  he  shall  make  a 
written  declination  to  perform  that  duty.  The  intent  of  the 
law  is  to  aid  the  physician  if  he  wishes  to  treat  the  case,  and  to 
relieve  him  of  responsibility  if  he  is  unable  or  unwilling  to 
carry  out  all  the  troublesome  measures  which  are  necessary  for 
preventing  the  spread  of  the  disease. 

Vital  Statistics. — Physicians  in  most  states  are  required  to 
report  births  and  to  certify  the  causes  of  deaths.  These  reports 
form  a  part  of  the  records  of  state  departments  of  health,  and 


THE   PHYSICIAN   AND    THE   HEALTH    OFFICER  55 

are  often  of  great  legal  and  financial  importance.  The  family- 
physician  often  fails  to  realize  that  he  is  an  essential  part  of  the 
governmental  machinery  for  registration  when  he  signs  a  simple 
certificate  of  birth  or  death;  and  he  is  often  correspondingly- 
angry  when  he  is  subjected  to  a  penalty  for  improperly  perform- 
ing that  duty.  Physicians  are  required  to  perform  these  duties 
for  little  or  no  pay,  but  the  theory  of  the  law  is  that  the  duties 
are  simple  in  their  nature,  and  are  to  be  rendered  as  a  slight 
return  for  the  exclusive  privilege  to  engage  in  the  remunerative 
profession  of  practising  medicine. 

Clinics. — The  departments  of  health  of  some  states,  counties, 
and  cities  conduct  clinics  for  the  diagnosis  and  treatment  of 
cases  of  tuberculosis,  venereal  diseases,  and  paralysis  following 
poliomyelitis,  and  for  the  correction  of  the  defects  of  school 
children.  Many  physicians  seek  to  avoid  cases  of  these  diseases, 
particularly  those  whose  victims  are  unable  or  unwilling  to  fol- 
low instructions.  The  treatment  of  these  conditions  is  largely 
a  public  health  problem  which  the  majority  of  physicians  are 
unable  or  unwilling  to  carry  out,  and  it  must  be  done  by  the 
department  of  health  or  other  organized  agency  if  it  is  done  at  all. 

Physical  Examinations.— The  laws  of  some  municipalities  re- 
quire the  examination  of  cooks  and  waiters  in  restaurants. 
These  examinations  are  usually  done  by  officials  of  the  depart- 
ment of  health  upon  the  same  principle  that  life  insurance  com- 
panies require  apphcants  for  insurance  to  be  examined  by 
physicians  chosen  by  the  company. 

Private  Physicians  and  Health  Departments. — Physicians 
often  complain  that  departments  of  health  are  encroaching  on 
their  rights  and  privileges  by  conducting  clinics  and  administer- 
ing treatments.  The  clinics  and  treatments  are  for  the  benefit 
of  those  who  cannot  obtain  relief  in  any  other  way,  and  are 
similar  to  those  conducted  by  hospitals  and  medical  schools. 
They  educate  the  public  in  scientific  preventive  medicine,  and 
popularize  modern  methods  of  diagnosis  and  treatment.  If 
physicians  wish  to  assume  any  of  the  duties  and  responsibilities 
now  devolving  upon  departments  of  health,  they  will  be  cordially 
welcomed.  But  experience  shows  that  the  great  majority  of 
cases  treated  in  the  department  clinics  would  remain  untreated 
if  public  health  officials  did  not  follow  them  up.  Few  physicians 
will  accept  the  responsibility  for  quarantining  their  own  cases 
of  contagious  disease,  but  they  usually  accept  the  varied  forms 
of  assistance  that  are  offered  to  them  by  departments  of  health. 
The  benefits  which  physicians  receive  from  departments  of 
health  far  outweigh  the  small  losses  and  inconveniences  which 
are  caused  by  the  departments'  activities. 


CHAPTER  VI 
RURAL  PUBLIC  HEALTH  WORK 

Death-rates  in  City  and  Country. — The  influences  which 
affect  health  may  be  divided  into  those  which  are  external  to 
man's  body  and  those  which  are  internal.  The  external  influ- 
ences are  those  of  man's  environment,  and  include  such  things 
as  fresh  air,  pure  water,  sunshine,  cleanliness  of  houses  and 
yards,  and  proper  sewage  disposal.  The  internal  influences  are 
those  which  exist  within  the  human  body  itself.  They  include 
communicable  diseases,  disease  germ  carriers,  immunity  and 
susceptibiHty,  education,  and  personal  habits,  such  as  those  of 
cleanliness  of  the  body,  coughing,  sneezing,  and  the  disposal  of 
excretions. 

Man's  environment  in  the  city  is  naturally  unhealthful, 
and  the  unhealthful  internal  influences  are  increased  by  the 
frequent  contact  of  persons  with  one  another  in  crowded  sections. 
The  environment  in  rural  districts  is  naturally  healthful,  and  the 
internal  influences  which  lead  to  sickness  are  far  less  than  in 
cities,  owing  to  the  separation  of  the  people  from  one  another. 
The  effects  are  shown  by  the  death-rates  which  formerly  ranged 
between  30  and  40  per  1000  in  the  city,  and  were  below  20  in 
the  country. 

The  first  boards  of  health  were  organized  in  cities,  and  their 
efforts  were  directed  principally  against  external  influences  in 
order  to  imitate  the  natural  conditions  of  the  country.  Pure 
water  was  introduced,  back  yards  and  streets  were  cleaned, 
sanitary  conveniences  were  installed  in  the  tenements,  sewers 
were  constructed,  garbage  collection  was  instituted,  and  a  begin- 
ning was  made  in  the  supervision  of  milk  and  other  foods.  The 
result  was  the  elimination  of  the  grosser  avenues  of  infection, 
a  great  reduction  in  the  so-called  filth  diseases,  such  as  typhoid 
and  cholera,  and  a  very  considerable  lessening  of  the  death- 
rates.  The  death-rate  in  New  York  City  in  1900  was  20.6, 
while  it  was  15.5  in  rural  districts  of  the  state,  which  included 
villages  having  a  population  of  8000  and  less.  This  was  justly 
considered  to  be  a  great  achievement,  and  it  is  probable  that  the 
practical  limits  were  reached  in  health  work  directed  against 
man's  environment.  But  this  work  scarcely  touched  the  rural 
districts,  for  their  conditions  were  already  ideal  according  to  the 
standpoint  of  the  city  sanitarians  of  a  generation  ago. 
56 


RURAL  PUBLIC  HEALTH   WORK 


57 


The  next  step  in  public  health  work  was  the  application  of 
modern  discoveries  in  preventive  medicine  to  the  internal  influ- 
ences which  affect  the  health  of  human  beings.  The  sick  indi- 
vidual was  inspected,  the  carrier  of  disease  germs  was  controlled, 
the  private  routes  by  which  disease  germs  passed  from  one  indi- 
vidual to  another  were  blocked;  child  hygiene  work  was  begun, 
infant  welfare  stations  were  established,  and  a  wide-spread  cam- 
paign of  personal  education  of  the  people  was  inaugurated.  The 
result  was  a  progressive  fall  in  the  death-rates  of  cities  where  the 
work  was  done  efficiently,  while  the  death-rate  showed  a  tend- 


DEATH  RATE  IN  NEW  YORK  CITY  COMPARED  WITH  DEATH 

RATE  IN  RURAL  NEW  YORK 

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Fig.  1. — Heavy  black  line  shows  decline  in  death-rate  of  New  York  City, 
Dotted  line  shows  recent  increase  in  death-rate  of  rural  New  York  (villages  below 
8000  population  classed  as  rural) .  Note  that  New  York  City  loses  fewer  lives  in 
proportion  to  population  than  does  the  rural  portion  of  the  state. 


ency  to  rise  in  rural  sections  where  the  work  was  unorganized. 
The  death-rate  of  New  York  City  was  almost  exactly  that  of 
the  rural  districts  in  1910  (15.9  city  and  15.8  rural),  and  has 
been  below  that  in  rural  districts  ever  since.  The  rates  in  1915 
were  13.9  for  New  York  City  and  14.5  for  the  rural  districts  of 
the  state.  The  change  is  due  almost  wholly  to  the  efficient 
health  work  in  cities.  The  country  no  longer  needs  health 
protection  against  the  city,  but  the  city  must  be  protected  against 
the  unhealthful  influences  of  the  rural  districts.  The  pubHc 
health  problem  of  the  future  is  to  bring  the  work  of  the  country 
up  to  the  standard  of  that  in  the  city. 


58  THE   HEALTH    OFFICER 

Rural  health  districts  may  be  di\-ided  into  three  groups: 
1,  the  rural  proper;  2,  the  unincorporated  villages;  3,  the  incor- 
porated villages.  The  problems  in  these  groups  differ  from  one 
another  almost  as  much  as  they  differ  from  those  in  the  cities. 
The  rural  districts  afi'ord  concrete  illustrations  of  the  evolution 
of  public  health  work  from  its  crude  undilTerentiated  beginnings 
up  to  its  specialized  activities  in  the  larger  progressive  villages. 

Sparsely  Settled  Townships. — Each  household  in  a  sparsely 
settled  township  is  an  independent  entity,  and  its  isolation  ren- 
ders an  elaborate  system  of  public  health  administration  as  un- 
necessary as  a  complex  system  in  its  other  governmental  activ- 
ities. The  two  problems  wdth  which  the  health  officer  deals 
principally  are  the  control  of  contagious  diseases  and  the  dis- 
posal of  human  wastes.  If  the  natural  environment  were  the 
principal  factor  in  causing  disease,  those  who  dwell  in  country 
districts  w^ould  be  almost  entirely  free  from  communicable  dis- 
eases. But  colds,  consumption,  and  diarrheas  are  as  common  in 
rural  townships  as  in  villages  and  cities.  A  hot,  close  kitchen 
is  usually  the  sitting-room  and  dining-room  for  the  whole  family, 
and  when  a  child  contracts  a  cold,  the  disease  spreads  through 
the  whole  household.  Overcrowding  of  rooms,  which  is  the 
most  dangerous  form  of  overcrowding,  is  as  common  in  the 
country  as  in  the  large  cities.  This  overcrowding,  and  the 
frequent  lack  of  a  sufficient  water-supply,  facilitate  the  spread 
of  colds  and  other  respiratory  diseases. 

The  spread  of  diarrheas  in  rural  districts  is  promoted  by  the 
primitive  system  of  disposing  of  human  wastes.  The  receptacles 
of  outdoor  water-closets  are  often  overflowing  and  swarming 
with  flies,  and  whatever  infectious  material  is  deposited  is  soon 
carried  back  to  food  and  to  persons.  Diarrhea  frequently  at- 
tacks one  person  after  another  in  a  family,  and  is  often  ascribed 
to  green  fruit,  when,  in  reality,  it  is  caused  by  infection  from  the 
outdoor  toilet. 

Most  infectious  diseases  affect  either  the  organs  of  respira- 
tion or  those  of  digestion,  and  people  in  rural  districts  usually 
diagnose  them  as  simple  colds  or  diarrheas,  at  least  in  their 
early  stages  and  in  mild  cases.  They  delay  calling  a  physician 
owing  to  the  expense,  and  in  the  meantime  no  precautions  are 
taken  during  the  most  infectious  periods  of  the  diseases.  Mild 
cases  and  carriers  are  often  missed,  and  it  is  probable  that  in 
strictly  rural  communities  only  about  half  of  the  cases  of  com- 
municable diseases  are  reported  to  the  health  officer.  The 
menance  of  the  city  by  the  country  in  health  matters  is  now 
greater  than  that  of  the  country  by  the  city,  and  the  affliction 
of  the  cities  with  milk-borne  epidemics  is  developing  a  demand 


RURAL  PUBLIC   HEALTH    WORK  59 

for  efficient  preventive  work  in  rural  districts.  The  greatest 
immediate  need  in  rural  health  work  is  the  organized  means  for 
detecting  and  controlling  communicable  diseases  in  their  early 
and  mild  stages. 

The  health  officer  of  a  rural  township  seldom  has  a  public 
health  nurse  to  assist  him  or  a  civic  club  to  encourage  him  in 
his  preventive  work.  Even  complaints  of  neighbors  against  one 
another  are  seldom  made,  for  unclean  conditions  arouse  no  in- 
terest when  people  live  an  eighth  of  a  mile  or  more  apart.  Each 
person  considers  himself  to  be  free  from  danger  of  contamination 
from  a  distant  neighbor,  and  he  resents  the  suggestion  that  he 
himself  may  damage  his  neighbor's  health.  The  health  officer 
must  deal  with  each  household  as  a  unit.  He  can  make  only  a 
beginning  in  co-operative  health  measures,  which  are  the  essence 
of  health  work  in  cities.  The  basis  of  his  work  is  personal  hy- 
giene; but  a  great  incentive  to  personal  hygiene  is  social  contact 
with  other  persons.  The  customs  of  polite  society  require  cer- 
tain standards  of  cleanliness  and  personal  appearance,  and  of 
freedom  from  apparent  signs  of  disease.  Famihes  living  in 
isolated  places  relapse  into  unsanitary  personal  habits  of  which 
they  are  ashamed  when  others  see  them.  The  lack  of  civic 
pride  and  of  the  incentive  of  fashion  makes  the  work  of  the  rural 
health  officer  especially  difficult. 

The  great  need  in  public  health  work  in  sparsely  settled  com- 
munities is  the  education  of  individuals  regarding  the  relation 
of  their  own  personal  habits  to  disease,  and  particularly  regard- 
ing the  infectious  nature  of  colds  and  diarrheas.  Personal 
education  rather  than  compulsion  will  solve  the  problem  of  health 
in  purely  rural  communities.  The  rural  health  officer  has  the 
power  to  control  evident  cases  of  contagious  diseases,  but  that 
is  about  all  the  direct  authority  he  can  use.  He  must  depend 
on  education  for  accomphshing  results  in  other  lines  of  public 
health  work. 

Unincorporated  Villages.— An  unincorporated  village  has  all 
the  problems  of  a  purely  rural  district,  but  other  problems  de- 
velop in  proportion  to  the  closeness  with  which  the  people  are 
associated  together.  Milk  routes  may  need  the  health  officer's  at- 
tention, and  water-supplies  may  require  protection.  The  cesspool 
nuisance  is  added  to  that  of  privies,  and  a  co-operative  sewage  dis- 
trict may  be  demanded.  The  necessity  for  co-operation  in  health 
protection  becomes  evident,  a  few  specific  lines  of  definite  work 
begin  to  be  apparent,  and  the  effects  of  civic  pride  begin  to  be 
felt.  The  health  officer  receives  complaints  of  unsanitary  condi- 
tions, and  he  can  secure  the  co-operation  of  at  least  a  small 
group  of  citizens  in  remedying  unhealthful   conditions.     The 


60  THE   HEALTH    OFFICER 

people  see  him  when  he  inspects  a  nuisance  or  visits  a  case  of 
sickness,  and  his  actions  receive  immediate  publicity.  His 
health  work  is  of  a  real  public  nature  in  distinction  from  its 
individual  character  in  sparsely  settled  communities. 

An  unincorporated  village  and  its  surrounding  rural  township 
usually  form  a  single  political  unit  which  is  served  by  one  health 
officer  and  one  board  of  health.  The  village  is  simply  a  thickly 
settled  portion  of  the  township,  and  its  health  officer  must  recon- 
cile the  demands  of  the  two  conflicting  groups.  The  people  of 
the  strictly  rural  section  assert  their  individual  independence, 
while  those  of  the  village  demand  some  degree  of  co-operation  in 
health  matters.  The  health  officer  will  naturally  devote  most  of 
his  activities  to  the  village  with  the  expectation  that  the  work 
will  spread  into  the  surrounding  rural  sections. 

Incorporated  Villages. — All  the  principal  activities  of  a  city 
department  of  health  are  needed  in  an  incorporated  village,  and 
they  are  at  least  brought  to  the  serious  attention  of  the  health 
officer  and  the  board  of  health  by  civic  clubs  and  other  organiza- 
tions which  now  exist  in  nearly  every  village.  Communicable 
diseases,  milk,  water,  sewage,  and  garbage  all  require  attention. 
A  health  officer  cannot  do  his  duty  unless  he  has  a  knowledge 
of  the  elements  of  all  phases  of  public  health  work,  and  is  willing 
to  give  his  time  to  developing  the  various  activities  which  he 
is  expected  to  conduct.  Two  very  great  advantages  of  an  in- 
corporated village  over  a  township  are  that  responsibility  in  a 
village  is  centralized  in  a  small  governing  body  to  whom  a 
health  officer  can  go  for  authority  and  help,  and  that  there  is 
usually  a  considerable  degree  of  civic  pride  to  arouse  the  people 
to  do  their  duty.  There  is  probably  as  much  public  health  work 
to  do  among  a  strictly  rural  population  of  5000  as  in  a  village  of 
5000;  but  there  will  be  ten  times  as  much  work  done  in  the 
village  as  in  the  rural  section. 

A  conscientious  village  health  officer  will  often  be  over- 
burdened with  a  mass  of  detailed  work,  and  it  may  be  neces- 
sary to  supply  him  with  helpers.  The  assistants  whom  he  will 
need  at  first  are  a  public  health  nurse  to  look  after  persons  them- 
selves, and  an  inspector  to  look  after  their  environment.  The 
nurse  will  follow  up  school  children  who  have  physical  defects. 
She  will  instruct  parents  in  the  care  of  babies,  and  will  investigate 
carriers  and  mild  cases  of  communicable  disease.  She  will  do 
child  hygiene  and  infant  welfare  work,  and  will  discover  and  su- 
pervise tuberculosis  cases.  Her  work  will  be  largely  house-to- 
house  visitations  and  private  demonstrations  of  methods  of 
home  sanitation. 

The  inspector  will  look  after  outdoor  conditions,  and  will 


RURAL  PUBLIC  HEALTH   WORK  61 

also  make  inspections  of  markets  and  school  buildings.  He  will 
investigate  water,  sewage,  milk,  food,  garbage,  and  nuisances. 
A  nurse  will  also  do  some  of  this  work  as  she  goes  her  rounds, 
and  if  only  one  assistant  is  provided,  the  health  officer  will 
choose  the  nurse.  He  will  add  other  assistants  as  the  work 
grows  and  new  activities  develop.  The  public  health  work  of 
many  progressive  villages  could  well  be  taken  as  a  model  for  the 
work  in  cities. 

Organization  of  a  Rural  Health  Department. — A  rural  health 
department  has  almost  no  organization,  and  little  differentiation 
of  health  activities.  The  rural  class  includes  nearly  all  the  health 
departments  of  townships  and  unincorporated  villages.  Over 
half  of  the  local  health  departments  of  New  York  State  may  be 
classed  as  strictly  rural. 

The  rural  health  officer  districts  in  most  states  are  independ- 
ent entities,  and  are  not  under  the  control  of  supervising  experts. 
The  states  usually  grant  home  rule  in  health  matters  to  the 
larger  cities,  and  the  rural  districts  demand  the  same  inde- 
pendence of  control.  The  result  is  that  efficiency  of  a  rural 
health  department  usually  depends  almost  entirely  upon  the 
local  health  officer  himself. 

The  New  York  State  plan  of  organization  is  that  the  local 
health  department  and  the  State  Department  of  Health  are 
jointly  charged  with  the  administration  of  local  health  affairs. 
The  responsibility  lies  first  with  the  local  department,  and, 
second,  with  the  State  Department.  This  plan  enables  the 
State  Department  to  set  uniform  standards  for  rural  departments; 
and  the  local  departments  to  obtain  expert  assistance  when  un- 
usual conditions  arise. 

Massachusetts  and  New  York  have  tried  the  plan  of  con- 
solidating local  health  districts  into  larger  units  in  which  effective 
health  work  can  be  done.  The  plan  works  well  when  a  village 
or  small  city  is  a  dominating  center  for  a  surrounding  rural  dis- 
trict. It  extends  the  organization  of  thfe  village  or  city  into  the 
surrounding  rural  districts. 

Indiana  and  other  states  have  adopted  the  plan  of  admin- 
istering health  affairs  by  means  of  county  health  officers  who 
have  deputies  in  the  local  districts. 

All  the  plans  of  organization  have  the  common  element  of  a 
local  health  officer  or  deputy  in  each  rural  district.  The  prin- 
cipal responsibility  for  field  work  h'es  with  the  local  officer, 
whether  he  is  independent  of  outside  control  or  is  subordinate 
to  a  higher  department  of  health  in  a  district,  county,  or  state. 
One  of  the  greatest  needs  in  public  health  work  is  that  for  ef- 
ficient  rural   health   officers.     The   efficiency   depends   on    (1) 


62  THE   HEALTH    OFFICER 

securing  the  proper  t\pe  of  men,  and  (2)  instructing  them  and 
giving  them  assistance  in  emergencies  and  difficult  conditions. 

Type  of  Health  Officer. — Three  t\^es  of  men  are  not  adapted 
to  be  rural  health  officers.  The  first  type  is  the  medical  poh- 
tician;  the  second  t}pe  is  the  self-willed,  independent  local 
physician  who  gets  his  medical  science  from  the  daily  newspapers, 
and  is  afraid  to  call  a  brother  physician  into  consultation.  The 
third  t}-pe  is  the  city  official  who  is  trained  to  follow  inflexible 
city  methods,  and  who  always  acts  by  rule.  The  physician 
that  makes  the  best  rural  health  officer  is  the  pubhc-spirited 
practitioner  of  medicine  who  understands  rural  conditions,  who 
knows  the  psychology  of  the  rural  mind,  and  who  himself  has  a 
successful  medical  practice  in  a  rural  district.  This  t}^e  of 
man  will  handle  the  various  emergency  conditions  in  pubHc 
health  just  as  efficiently  as  he  does  the  graver  and  more  severe 
diseases  in  his  medical  and  surgical  practice.  He  will  recognize 
serious  conditions  in  their  early  stages,  and  will  seek  the  advice 
and  assistance  of  expert  speciaKsts,  or  of  his  superior  officers, 
before  conditions  get  beyond  his  control.  He  will  succeed  in 
whatever  he  undertakes,  and  if  a  way  to  success  is  not  apparent, 
he  will  not  be  content  until  he  makes  one.  The  number  of  avail- 
able men  of  this  t^pe  is  sufficient  to  fill  every  position  of  health 
officer,  and  if  boards  of  health  would  choose  men  of  this  class, 
rural  health  work  would  be  done  as  efficiently  as  health  work  in 
the  cities. 

Training  for  Health  Officership. — ^A  rural  health  officer  re- 
quires training  in  his  specialty.  New  York  requires  its  health 
officers  to  fit  themselves  for  their  duties,  supervises  them  in  their 
work,  and  gives  them  assistance  in  emergencies.  The  ideal 
condition  is  that  in  which  the  local  health  officers  bear  the  same 
relation  to  their  supervisors  in  their  state  department  of  health 
that  the  family  physician  bears  to  a  consultant  or  to  an  operat- 
ing surgeon.  Rural  health  work  will  become  efficient  when  a 
system  of  training,  supervising,  and  assisting  the  health  officers 
is  universally  adopted. 


CHAPTER  VII 
RECORDS  AND  REPORTS 

Reasons  for  Keeping  Records. — The  average  health  officer  is 
a  modest  official,  and  his  training  as  a  private  practitioner  of 
medicine  has  taught  him  to  refrain  from  talking  about  his  work 
and  accomplishments.  His  duties  at  any  one  time  are  usually 
so  few  that  he  can  carry  his  acts  in  memory  to  his  own  satisfac- 
tion. But  there  are  three  great  reasons  why  he  should  keep 
records  and  make  public  reports  of  the  items  of  work  which  he 
does. 

The  first  reason  why  a  health  officer  should  give  publicity 
to  his  work  is  that  he  is  a  pubhc  official,  and  the  people  whom  he 
serves  have  a  right  to  know  what  he  is  doing.  They  may  reason- 
ably demand  that  he  take  them  into  his  confidence  regarding 
public  health  conditions,  just  as  private  persons  may  expect 
him  to  advise  them  frankly  and  fully  regarding  their  personal 
diseases.  If  a  health  officer  does  not  consider  his  advice  and 
treatment  of  the  public  to  be  of  sufficient  importance  to  require 
a  record  of  the  items,  the  people  will  naturally  place  a  small 
value  on  his  services  and  on  the  cause  which  he  represents.  But 
a  truthful  statement  and  enumeration  of  the  details  of  the  varied 
duties  which  he  performs  will  lead  the  people  to  appreciate  the 
value  of  his  diagnosis  and  treatment  of  pubhc  ills,  and  to  give 
him  their  co-operation  in  the  promotion  of  pubhc  health. 

The  second  reason  for  keeping  records  and  making  reports 
is  that  they  may  be  used  as  a  basis  on  which  the  board  of  health 
may  authorize  work  for  the  coming  year  and  make  the  proper 
appropriations  for  carrying  it  on.  When  a  health  officer  asks 
for  an  appropriation,  the  members  of  the  board  of  health  may 
properly  ask  two  questions:  first,  What  has  the  health  officer 
done  during  the  past  year?  and  second.  Exactly  what  does  he 
propose  to  do  during  the  coming  year?  They  will  also  ask.  Do 
the  people  want  this  work  done?  The  answers  to  these  three 
questions  will  necessarily  be  based  on  the  records  and  reports 
which  are  on  file  in  the  department  of  health.  The  health  officer 
may  have  the  records  stored  away  in  his  own  memory,  but  they 
are  of  no  value  until  they  are  in  written  form  and  available  to 
the  pubhc.  The  people  act  on  the  information  which  they 
possess.  A  universal  rule  in  American  government  is  that 
appropriations  of  money  shall  be  made  only  in  response  to  a 

63 


64  THE   HEALTH    OFFICER 

clear  public  statement  of  the  exact  conditions  which  require 
the  expenditures.  A  health  officer  owes  a  duty  to  the  people 
to  advise  them  regarding  conditions  affecting  public  health, 
what  he  has  done  to  remedy  them,  and  what  he  considers  neces- 
sary in  the  future.  Health  officers  who  have  presented  these 
facts  clearly  in  detail  have  usually  found  their  boards  of  health 
and  the  people  to  be  responsive  to  their  requests. 

The  third  reason  for  making  records  and  reports  is  their 
effect  on  the  health  officer  himself.  When  he  makes  a  report, 
he  must  ask,  what  definite  thing  have  I  done,  and  what  definite 
results  will  come  from  it?  A  health  officer  must  have  a  con- 
scious knowledge  of  himself.  Records  and  reports  compel  him 
to  see  himself  as  others  see  him.  They  reveal  his  own  failures 
and  successes,  and  the  sources  of  his  weakness  and  his  strength. 

The  first  step  in  solving  a  problem  is  to  state  it  clearly.  A 
report  requires  a  health  officer  to  state  his  problems  in  concrete 
form.  Records  in  memory  are  crude,  unorganized  masses  of 
impressions.  A  written  report  is  an  organized  array  of  proved 
facts,  and  an  interpretation  of  their  meaning.  It  clarifies  the 
health  officer's  ideas  of  health  conditions  and  suggests  the 
proper  remedies.  Records  and  reports  constitute  an  index  of 
the  amount  of  thought  which  a  health  officer  puts  into  his  work. 

What  to  Record. — Every  act  to  which  a  health  officer  devotes 
time  and  thought  in  the  discharge  of  his  duty  is  worthy  of 
record.  His  field  activities  are  enumerated  on  page  22,  and 
his  office  duties  on  page  30.  The  performance  of  each  activity 
in  a  city  department  of  health  is  assigned  to  one  or  more  per- 
sons, and  a  separate  record  is  kept  of  each  individual.  Each 
activity  that  a  country  health  officer  conducts  is  as  important 
as  a  similar  activity  in  a  city.  A  health  officer,  for  example, 
is  his  own  telephone  operator,  and  the  time  which  he  spends  in 
making  calls  is  even  more  important  than  that  of  the  telephone 
girl  in  the  city  department.  While  a  health  officer  is  not  ex- 
pected to  keep  a  record  of  every  small  item  of  work,  yet  he  ought 
to  have  some  idea  of  the  amount  of  time  which  he  devotes  to 
each  activity.  He  can  estimate  this  by  keeping  a  record  of  one 
item  at  a  time  for  a  short  time.  He  may,  for  example,  estimate 
the  number  of  letters  which  he  receives  and  sends  by  counting 
them  for  a  week  or  a  month. 

Classification  of  Records  and  Reports. — The  records  and  re- 
ports which  every  health  officer  may  reasonably  be  expected 
to  make  may  be  classified  under  seven  heads:  1,  a  diary;  2,  a 
note-book;  3,  a  permanent  record  book;  4,  individual  reports 
on  special  work;  5,  monthly  reports;  6,  annual  reports;  7,  plans 
for  future  action. 


RECORDS   AND   REPORTS  65 

Diary. — The  simplest  record  which  a  health  officer  can  make 
is  a  brief  daily  account  of  the  various  items  of  his  work.  He 
can  make  the  record  in  his  personal  diary  or  in  a  special  book 
which  he  carries  for  the  purpose.  A  daily  record  is  necessary  in 
conducting  isolations  and  quarantines,  making  inspections  and 
investigations,  and  in  making  up  final  reports.  It  is  also  neces- 
sary in  noting  future  engagements. 

A  Note-book. — A  necessary  part  of  the  outfit  of  every  health 
officer  is  a  note-book  in  which  he  may  make  field  records  of  data 
concerning  inspections,  investigations,  and  conferences,  and  the 
examinations  of  cases  of  communicable  diseases.  A  convenient 
form  is  a  book  with  loose  leaves  measuring  about  4x7  inches. 
A  book  of  this  size  may  be  conveniently  carried  in  the  coat 
pocket,  and  is  always  ready  for  immediate  use.  The  leaves  may 
be  removed  and  tied  together  for  future  reference.  No  one 
can  trust  to  memory  for  recalling  names,  addresses,  dates,  dis- 
tances, and  other  items  whose  value  depends  upon  their  accu- 
racy. Notes  made  at  the  time  of  observation  will  be  accepted 
as  valid  evidence  in  most  law  courts.  It  is  an  excellent  plan 
for  every  health  officer  to  form  the  habit  of  taking  notes 
of  every  important  condition  which  he  observes,  particularly 
if  there  is  likeHhood  of  future  dissatisfaction  or  dispute.  Mak- 
ing the  no^es  requires  no  extra  time,  and  the  action  im- 
presses the  bystanders  with  the  accuracy  and  carefulness  of 
the  health  officer.  A  field  note-book  is  hke  the  day  book  of  a 
merchant. 

Permanent  Record  Book. — It  is  the  duty  of  every  health 
officer  to  keep  a  permanent  and  consecutive  record  of  his  prin- 
cipal activities.  This  book  is  like  the  ledger  of  a  merchant. 
The  health  officer  will  frequently  refer  to  it  in  making  up  his 
reports  and  in  answering  inquiries  regarding  health  conditions 
in  his  district.  If  it  is  kept  up  to  date,  it  will  constitute  a  sum- 
mary of  the  main  Hnes  of  work  of  the  health  officer. 

The  Department  of  Health  of  New  York  State  has  prepared 
a  health  officer's  record  book  in  which  there  are  ruled  pages  for 
recording  the  following  items : 

Communicable  diseases. 

Complaints  and  nuisances. 

Registration  of  deaths  without  medical  attendance. 

Commitments  for  insanity. 

Inspections  of  public  buildings. 

Milk  permits. 

Expenses. 

SuppHes  received  and  distributed. 

Miscellaneous. 


66  THE   HEALTH    OFFICER 

Reports  of  Special  Work. — A  health  officer  is  often  requested 
to  investigate  epidemics  and  unsanitary  conditions,  and  to 
write  reports  on  his  findings  and  actions.  A  frequent  defect  in 
the  reports  is  that  they  are  incomplete  and  confused,  are  illogic- 
ally  arranged,  and  lack  unity  of  construction.  The  style  of  a 
newspaper  reporter  is  a  good  one  for  a  health  officer  to  follow  in 
making  his  report.  The  questions  who?  what?  when?  and  where? 
are  to  be  answered  in  the  first  few  lines  of  the  report,  and  the 
details  are  then  to  be  set  forth.  A  model  fomi  of  report  is  that 
adopted  by  the  New  York  State  Department  of  Health.  It  is 
in  the  form  of  a  letter  in  which  the  subjects  of  the  paragraphs 
are  arranged  in  the  natural  order  of  the  development  of  the 
investigation.  After  the  usual  superscription  the  standard  form 
of  the  letter  and  the  order  of  the  paragraphs  may  run  about  as 
follows : 

1.  The  following  report  is  submitted  on  the  investigation 
of  (state  the  condition),  at  (place),  on  (date),  in  response  to  the 
(order,  complaint,  or  information)  given  by  (name  of  party),  and 

received  on  (date),  that (give  a  brief 

summary  of  the  order,  complaint,  or  information) . 

2.  Give  other  reasons,  if  any,  for  making  the  investigation. 

3.  Describe  the  conditions  that  you  found,  being  sure  to 
include  names,  addresses,  dates,  and  accurate  figures  as  nearly 
as  possible. 

■i.  Describe  the  action  which  you  took. 

5.  State  the  advice  which  you  gave,  and  the  recommenda- 
tions which  you  made. 

6.  State  the  attitude  of  the  persons  to  whom  you  gave  the 
advice,  and  give  your  opinion  whether  or  not  they  will  follow 
your  advice. 

7.  Sign  your  name  and  give  your  official  title. 

Monthly  Report. — It  is  a  good  plan  for  the  health  officer  to 
submit  a  monthly  report  to  his  board  of  health,  and  to  discuss 
and  explain  it  personally  to  the  board.  The  reports  will  usually 
be  published  in  the  local  newspapers,  and  will  help  to  educate 
the  public  as  well  as  members  of  the  board.  A  model  form  of 
report  is  that  which  the  New  York  State  Department  of  Health 
requires  from  every  health  officer.  It  is  made  on  a  blank  which 
is  supplied  by  the  department,  and  consists  chiefly  of  a  statistical 
summary  of  the  work  performed.  It  has  spaces  for  the  follow- 
ing items: 

1.  Number  of  cases  of  the  various  communicable  diseases 
reported. 

2.  Number  of  special  conferences  on  health  matters  at- 
tended. 


RECORDS   AND    REPORTS  67 

3.  Number  of  hours  devoted  to  health  matters  during  the 
month. 

4.  Amount  of  money  audited  by  the  board  of  health  during 
the  month. 

5.  Number  of  public  buildings  or  schoolhouses  examined. 

6.  Number  of  premises  cleaned, ;  renovated, ;  dis- 
infected,   . 


7.  Number  of  dairies  scored, . 

8.  Number  of  permits  issued  to  milk  dealers, 

9.  Number  of  other  permits  given, . 

10.  Number  of  lectures  given,  or  managed, 


11.  Number  of  board  of  health  meetings  attended, . 

12.  Number  of  complaints  received, ;  investigated, ; 

satisfied, . 

13.  Number  of  sanitary  inspections  made, . 

14.  Number  of  other  items  of  health  officer  work  performed, 


15.  Amount  of  supplies  given  out, . 

16.  Remarks  and  explanations. 

Annual  Report. — The  annual  report  is,  in  effect,  a  sanitary 
survey  of  the  health  officer's  district.  It  consists  of  a  sum- 
mary of  the  statistics  contained  in  the  monthly  reports,  together 
with  explanations  and  interpretations  of  the  statistics.  It  also 
contains  a  summary  of  the  vital  statistics  of  the  year,  an  estima- 
tion of  the  birth-,  death-,  and  infant  mortahty  rates,  a  com- 
parison of  them  with  the  rates  for  the  preceding  years,  and  a 
discussion  of  the  various  causes  of  death.  It  further  contains  a 
summary  and  discussion  of  the  following  topics: 

1.  Milk-supply;  the  amount  of  milk  and  cream  sold,  the 
number  of  dealers,  number  of  producers,  and  score  of  the  dairies, 
the  amount  pasteurized,  and  a  discussion  of  the  methods  of 
handling  the  milk. 

2.  Water-supply,  municipal  and  private  water  companies^ 
individual  supplies;  sources  of  the  water,  character  and  analysis; 
when  surveyed  or  analyzed. 

3.  Sewage  disposal;  sewers  and  disposal  plants,  and  their 
operation;  cesspools  and  methods  of  disposing  of  their  contents; 
privies,  their  construction  and  maintenance. 

4.  Garbage  disposal,  methods  and  results  attained. 

5.  Refuse  disposal,  location  of  dumps;  methods  of  their 
control. 

6.  Stables  and  barnyards,  methods  of  their  control  and 
sanitation. 

7.  Antifly  and  antimosquito  work. 


68  THE   HEALTH    OFFICER 

8.  Midwives,  number  practising;  methods  of  their  oversight 
and  control. 

9.  Child  welfare  stations,  little  mothers'  leagues,  nurses,  and 
a  discussion  of  the  results  attained. 

10.  Public  health  nursing,  number  of  nurses;  their  activities; 
a  summary  of  their  work. 

11.  Antituberculosis  work,  nurses,  home  oversight,  sana- 
torium care,  educational  work. 

12.  Complaints,  their  classification,  means  employed  in  abat- 
ing nuisances,  results  obtained. 

13.  Laboratory,  nearest  one  available,  number  of  diphtheria 
cultures  taken;  number  of  sputum  examinations;  number  of 
Widal  tests;  number  of  Wassermann  tests;  number  of  typhoid 
vaccinations;  amount  of  supplies  received;  dispensed. 

14.  Expenses  for  the  health  officer's  pay;  for  supplies;  for 
disinfections;  for  vital  statistics;  for  other  purposes. 

15.  Vaccination  for  prevention  of  smallpox;  number,  results, 
methods  employed. 

16.  Educational.  Lectures  given;  lectures  managed;  ex- 
hibits; copy  for  newspapers  prepared;  interviews  given  to  re- 
porters; posters  and  circulars  prepared. 

The  statute  law  of  New  York  State  requires  every  health 
officer  to  make  a  survey  of  his  district  annually.  This  is  equiva- 
lent to  an  annual  report.  Its  preparation  will  not  be  difficult 
if  the  health  officer  keeps  his  monthly  reports  up  to  date,  and 
is  active  in  the  discharge  of  his  routine  duties. 

Program  for  Future  Work. — One  of  the  greatest  objects  of  a 
health  officer's  annual  report  is  to  arouse  interest  in  public 
health  work  in  his  municipality  in  the  future.  The  health 
officer  himself  is  the  first  person  who  may  be  expected  to  profit 
by  the  report  and  in  whom  an  increased  zeal  may  be  anticipated. 
If  he  makes  a  comprehensive  study  of  the  health  situation  while 
compiling  his  annual  report,  he  naturally  will  form  an  estimate 
of  the  peculiar  difficulties  which  he  has  had  to  meet,  and  will 
consider  plans  to  meet  them  and  to  increase  the  scope  and 
efficiency  of  his  work  during  the  coming  year.  It  is  his  duty  to 
include  in  his  annual  report  a  definite  program  for  the  work  of 
the  coming  year,  and  a  request  for  the  financial  assistance  of 
his  board  of  health  and  the  active  co-operation  of  its  members. 
It  is  a  good  plan  to  adopt  a  specific  aim,  such  as  the  care  or 
supervision  of  every  tuberculosis  case,  or  a  sanitary  toilet  for 
every  home,  or  the  estabhshment  of  a  dental  clinic,  or  the 
formation  of  a  sewer  district,  or  the  suppression  of  malaria,  or 
the  vaccination  of  every  school  child,  or  the  introduction  of  a 
pure  water-supply,  or  the  improvement  of  the  milk-supply,  or 


RECORDS   AND   REPORTS  69 

the  adoption  of  a  system  of  food  inspection,  or  the  employment 
of  a  public  health  nurse.  Experience  shows  that  if  one  object 
is  specially  emphasized,  public  health  work  along  all  other 
lines  will  be  promoted.  Each  municipality  has  its  own  peculiar 
problems  and  needs,  and  the  health  officer  can  suggest  the  line 
of  work  which  will  give  the  largest  results  for  the  money  and 
effort  invested. 

Daily  Record  Sheet. — There  is  great  need  that  a  health  officer 
shall  systematize  his  work,  and  shall  record  what  he  does  each 
day  in  his  varied  activities.  If  a  health  officer  were  working 
for  an  industrial  corporation,  he  would  be  required  to  keep  a 
daily  record  sheet  of  his  work.  Such  a  daily  statistical  record 
will  be  most  valuable  to  health  officers  who  are  willing  to  keep 
it,  and  to  boards  of  health  who  may  require  it.  The  form  on 
pages  70  and  71  is  suggested  as  a  model. 

Sanitary  Survey. — A  sanitary  survey  consists  of  a  record  of 
the  principal  sanitary  features  of  a  district.  It  is  desirable  that 
a  copy  of  the  survey  of  each  health  officer's  district  be  on  file  in 
the  local  office,  and  another  in  the  office  of  the  State  Department 
of  Health.  The  form  used  in  New  York  State  contains  the 
following  items: 

1.  Population;  age  grouping;  races. 

2.  Topography;  soil;  bodies  of  water. 

3.  Financial  expenditures  for  health  work, 

4.  Water-supplies;  sources;  purity;  records  of  analyses;  rec- 
ommendations made  by  the  State  Department  of  Health. 

5.  Sewage  disposal;  sewer  districts;  sewer  outfalls;  cesspools; 
privies;  relation  to  wells. 

6.  Disposal  of  other  household  wastes;  garbage;  manure; 
local  ordinances  regarding  them. 

7.  Nuisances,  the  common  ones;  factory  wastes. 

8.  Streets;  paved,  macadam,  or  dirt;  accidents  at  railroad 
crossings. 

9.  PubHc  buildings;  tenement  houses;  bath-rooms;  building 
regulations. 

10.  Schools,  number;  special  provision  for  tubercular  pupils; 
medical  inspection. 

11.  Hospital  provision  for  general  cases;  for  contagious  dis- 
eases; for  tuberculosis. 

12.  Labor  camps,  number;  character;  sanitary  conditions; 
permits  issued. 

13.  Summer  resorts;  inspections  made;  milk-suppHes;  water- 
supply,  sewage  disposal. 

14.  Barber  shops;  sanitary  condition. 


70 


THE    HEALTH    OFFICER 


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RECORDS    AND    REPORTS 


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72  THE  HEALTH   OFFICER 

15.  Dairies;  number,  average  score;  licensing;  general  char- 
acter of  the  milk-supply. 

16.  Special  sanitary  code  regulations;  common  towels;  drink- 
ing-cups;  spitting;  midwives. 

17.  Educational  work  done;  lectures;  number  of  persons 
reached;  conferences  attended  by  the  health  officer;  other  edu- 
cational work. 

18.  Miscellaneous;  board  meetings;  hours  devoted  to  public 
health  work  by  the  health  officer;  assistants;  lay  societies  co- 
operating; record  book;  tuberculosis  register. 

19.  Conclusions  regarding  the  special  needs  of  the  district; 
public  health  nurse;  other  assistants;  more  money;  laboratory; 
co-operation  of  the  board  of  health;  pure  water-supply;  sewer 
system;  educational  work;  better  milk-supply,  etc. 


CHAPTER  VIII 
STANDARD  PROCEDURES 

Information  to  the  Health  Officer. — The  health  officer  is  the 
executive  officer  and  field  agent  of  the  department  of  health. 
He  represents  both  the  state  and  the  local  departments,  and  is 
the  first  official  to  whom  nearly  every  health  condition  is  re- 
ferred. The  information  on  which  he  acts  comes  from  four 
principal  sources:  1,  The  reports  of  physicians,  overseers,  nurses, 
teachers,  and  other  persons  who  are  required  by  law  to  report 
certain  conditions  to  him;  2,  complaints  from  private  parties; 
3,  his  own  inspections  either  regular  or  special;  4,  requests  and 
orders  from  a  superior  officer,  board,  or  head  of  department. 
An  active  health  officer  will  not  depend  entirely  on  someone 
else  to  report  to  him  before  he  takes  action,  but  he  will  make 
inspections  and  investigations  at  every  opportunity  on  his  own 
initiative.  He  is  presumed  to  be  familiar  with  health  conditions 
in  his  district.  The  public  health  law  of  New  York  State  is 
mandatory  that  health  officers  shall  maintain  a  continuous 
sanitary  supervision  over  the  territory  within  their  jurisdiction 
(Sec.  21b,  Subdivision  1).  A  health  officer  of  a  rural  munici- 
pality is  usually  familiar  with  all  sections  of  his  district,  and 
knows  where  unsanitary  conditions  may  be  expected. 

Investigation. — When  the  knowledge  of  a  probable  unsani- 
tary condition  comes  to  him,  a  health  officer's  first  duty  is  to 
visit  the  place  himself,  or  send  a  competent  assistant,  and  make 
a  thorough  first-hand  investigation.  He  will  consult  all  the 
parties  who  are  concerned  in  the  unsanitary  condition,  and  will 
take  whatever  measures  are  necessary  to  determine  the  nature 
of  the  condition  and  the  identity  of  the  persons  who  are  re- 
sponsible for  it.  He  will  take  cultures  and  photographs  if  neces- 
sary, and  will  be  accurate  and  complete  in  his  observations.  If 
the  condition  is  that  of  a  communicable  disease,  he  will  consult 
the  physician  in  attendance,  and  will  assist  him  in  making  a 
diagnosis  and  in  carrying  out  protective  measures. 

The  health  officer  has  the  power  to  enter  upon  any  place  or 
premises  where  conditions  dangerous  to  health  are  known  or 
believed  to  exist,  and  may  make  inspections  and  examinations 
of  those  places  and  premises.  He  may  also  make  a  medical 
examination  of  persons  who  are  affected  with  or  have  been  ex- 

73 


74  THE   HEALTH    OFFICER 

posed  to  communicable  diseases  (New  York  Public  Health  Law, 
Sees.  25  and  26). 

There  is  a  question  how  much  force  a  health  officer  may 
legally  use  in  conducting  an  investigation.  If  he  is  denied  en- 
trance to  a  place  where  an  investigation  is  needed  immediately, 
the  best  course  for  him  to  pursue  is  to  call  a  poHce  officer  to 
accompany  him  and  assist  in  making  an  entrance.  If  a  medical 
examination  of  a  sick  person  is  refused,  it  would  be  his  duty  to 
institute  a  quarantine  or  a  lesser  degree  of  restriction  as  may  be 
indicated  by  the  probable  nature  of  the  disease.  But  a  health 
officer  who  is  respected  in  a  community  will  rarely  be  denied 
admission  or  refused  a  medical  examination,  especially  when  he 
makes  a  second  visit. 

A  health  officer  must  have  a  sound  and  sufficient  reason  to 
justify  him  in  forcing  an  entrance  upon  private  property,  in- 
vading the  privacy  of  an  individual,  or  restraining  the  liberty 
of  any  person.  He  may  be  called  to  court  to  answer  charges 
that  his  acts  were  unnecessary  and  unreasonable.  The  final 
decision  regarding  the  unsanitary  nature  of  any  person  or  thing 
does  not  rest  with  the  health  officer,  but  with  a  judge  or  jury 
in  a  court  of  law.  The  health  officer  must  be  sure  that  the  evi- 
dence on  which  he  acts  is  sufficient  to  convince  the  court  of  the 
legality  and  necessity  for  his  action. 

When  a  health  officer  makes  an  investigation  of  importance, 
it  is  necessary  that  he  make  written  notes  on  the  conditions  in 
order  to  be  sure  of  his  evidence.  The  date,  time  of  day,  place, 
and  persons  seen  are  all  of  great  importance.  If  a  conversation 
was  carried  on,  it  would  be  well  to  record  the  exact  words  which 
were  spoken.  If  a  health  officer  has  to  go  to  court,  he  may  take 
his  original  notes  with  him  to  the  witness  stand,  and  may  refer 
to  them  to  refresh  his  memory.  If  he  cannot  make  notes  at 
the  time  of  the  investigation,  he  may  make  them  soon  afterward 
while  the  condition  is  fresh  in  his  memory.  Written  records 
made  in  the  field  constitute  the  strongest  possible  evidence  of 
the  true  nature  of  the  conditions. 

Health  officers  in  some  of  the  states  are  protected  by  law 
against  personal  suits  for  their  official  acts  (New  York  Public 
Health  Law,  Sec.  21b).  But  if  a  judgment  is  obtained  against 
a  municipality  on  account  of  the  acts  or  negligence  of  the  health 
officer,  the  municipality  may  bring  suit  against  the  health 
officer. 

Decision. — After  a  health  officer  has  investigated  a  condition, 
he  must  make  a  decision  covering  two  points:  1,  whether  or  not 
it  may  affect  health;  2,  whether  or  not  it  may  involve  a  con- 
siderable number  of  persons.     It  is  a  general  rule,  to  which 


STANDARD   PROCEDURES  75 

there  may  be  exceptions,  that  a  health  officer  deals  only  with 
conditions  that  may  affect  the  health  of  a  considerable  number 
of  persons.  The  health  officer  must  also  decide  whether  or  not 
the  condition  is  a  direct  violation  of  a  law  or  a  sanitary  code. 

Notice. — The  third  step  which  a  health  officer  must  take  in 
dealing  with  an  unsanitary  condition  is  to  inform  the  respon- 
sible party  of  its  exact  nature,  and  to  suggest  a  remedy.  If 
there  is  a  section  of  statute  law  or  a  regulation  in  a  sanitary  code 
bearing  upon  the  condition,  the  health  officer  will  include  it  in 
the  information.  The  notice  and  information  may  be  oral  or 
written,  or  it  may  be  contained  in  printed  leaflets  such  as  those 
issued  by  the  New  York  State  Department  of  Health  on  the 
various  communicable  diseases.  If  a  person  on  whom  a  notice 
is  served  readily  agrees  to  remedy  a  condition,  an  oral  notice 
may  be  sufficient,  but  if  the  condition  is  complicated,  or  if  there 
is  doubt  about  its  being  remedied,  a  written  notice  is  essential. 
It  is  well  for  a  health  officer  to  retain  a  copy  of  the  notice  for  his 
own  protection  and  for  possible  evidence  in  court. 

While  ignorance  of  law  is  no  excuse  for  its  violation,  yet 
courts  and  juries  are  justly  lenient  with  those  who  presumably 
have  had  no  opportunity  to  learn  the  law.  But  a  broader  reason 
for  giving  the  notice  is  that  it  educates  those  to  whom  it  is  given. 
If  a  health  officer  gives  a  notice  in  a  friendly  way,  and  explains 
the  condition  in  a  simple  manner,  he  will  make  friends  with  the 
person  responsible  for  the  condition,  and  will  secure  his  co- 
operation in  remedying  it.  Most  persons  with  whom  a  health 
officer  has  to  deal  are  not  offenders  to  be  punished,  but  they  are 
innocent  parties  who  sincerely  desire  to  follow  common  sense 
instructions  which  they  understand. 

A  notice  given  by  a  health  officer  is  not  an  order,  and  a 
person  who  fails  to  comply  with  its  suggestions  may  not  be 
punished  for  disobedience.  Whatever  punishment  is  inflicted 
will  be  simply  for  maintaining  an  unhealthful  condition.  The 
notice  conveys  the  information  that,  in  the  health  officer's 
opinion,  an  unsanitary  condition  exists,  and  that  certain  proced- 
ures will  remedy  it.  The  force  of  the  notice  is  contained  in  a 
statement  that  is  usually  added  that,  if  the  condition  is  not 
remedied  within  a  certain  time,  legal  action  will  be  taken  against 
the  persons  responsible  for  it. 

The  health  officer  himself  has  no  power  to  enforce  his  orders 
except  in  conditions  in  which  a  contagious  disease  is  involved 
and  immediate  action  is  required.  But  even  in  an  emergency 
his  power  arises  from  the  force  of  pubhc  opinion  that  would 
bring  overwhelming  evidence  in  his  favor  if  the  case  should  come 
to  court.    The  ultimate  power  lies  not  with  the  health  officer, 


76  THE   HEALTH    OFFICER 

but  with  the  law  courts.  Forgetfulness  of  this  fact  often  in- 
volves health  officers  and  their  municipalities  in  difficulties  and 
needless  law  suits  for  unnecessary  and  illegal  acts. 

If  the  health  officer  cannot  secure  the  correction  of  an  un- 
sanitary condition  by  a  notice  and  explanation,  or  by  persuasion, 
he  may  do  one  of  three  things — 1,  take  summary  action;  2, 
begin  a  suit  at  law;  or,  3,  refer  the  matter  to  his  board  of  health 
or  the  state  department  of  health. 

Summary  Action. — If  a  condition  threatens  public  health 
with  a  great  and  immediate  danger,  the  health  officer  is  justified 
in  taking  summary  action  to  correct  the  condition  and  ward  off 
the  danger.  His  action  under  those  circumstances  is  like  that 
of  a  policeman  or  fireman.  The  principal  conditions  in  which 
a  health  officer  must  take  summary  action  are  those  which 
involve  a  contagious  disease  or  threaten  the  spread  of  disease 
germs.  A  health  officer  is  justified  in  posting  a  guard  at  the 
house  of  a  person  who  threatens  to  break  a  quarantine.  If  a 
person  afflicted  with  a  contagious  disease  leaves  his  home,  the 
health  officer  will  not  wait  to  obtain  a  warrant,  but  he  will  bring 
the  person  back  at  once,  and  by  force  if  necessary.  If  a  garbage 
heap  contains  the  discharges  from  a  typhoid  fever  patient,  the 
health  officer  may  properly  employ  a  laborer  to  bury  it  at  once. 

A  health  officer  who  acts  summarily  does  so  at  his  own  risk. 
The  danger  must  be  real  and  immediate  to  justify  his  action.  If 
no  danger  is  likely  to  result  from  a  few  hours'  or  days'  delay,  a 
health  officer  is  not  justified  in  taking  the  law  in  his  own  hands. 
For  example,  he  would  not  be  justified  in  using  force  in  order  to 
vaccinate  a  person.  But  a  health  officer  who  is  active  and  dis- 
crete may  count  on  the  support  of  his  board  of  health  and  the 
public  when  he  decides  that  summary  action  is  necessary.  It  is 
always  wise  for  a  health  officer,  before  he  takes  summary  action, 
to  consult  some  member  of  his  board  of  health,  if  possible, 
or  some  prominent  citizen  in  order  to  have  a  witness  as  to  the 
necessity  of  his  action.  It  is  his  duty  also  to  obtain  a  ratifica- 
tion of  his  action  by  the  board  as  soon  as  possible. 

Bringing  a  law  suit  is  not  the  duty  of  a  health  officer,  but  of 
a  board  of  health.  However,  the  matter  is  often  referred  to  a 
health  officer,  and  he  may  bring  an  action,  and  courts  and  public 
opinion  usually  uphold  him  in  doing  it. 

Action  by  a  Board  of  Health. — If  the  health  officer  is  unable 
to  secure  the  correction  of  an  unsanitary  condition  by  a  notice, 
explanation,  and  persuasion,  his  next  procedure  will  usually  be 
to  refer  the  matter  to  his  board  of  health.  If  the  nature  of  the 
condition  is  evident  and  the  remedy  is  obvious,  the  board  may 
not  need  to  meet,  but  the  president  or  some  member  of  the 


STANDARD   PROCEDURES  77 

board  may  advise  the  health  officer  or  other  representative  of 
the  board  to  bring  a  suit  against  the  offender  at  once.  If  there 
is  doubt  regarding  the  nature  of  the  condition  and  the  proper 
remedy,  it  is  the  duty  of  the  board  to  meet  and  consider  the 
matter  formally.  The  procedure  by  the  board  is  similar  to  that 
by  the  health  officer,  and  includes  three  steps;  1,  making  an 
investigation;  2,  forming  a  decision;  3,  issuing  an  order. 

A  board  of  health  may  make  an  investigation  in  one  of  three 
ways.  Individual  members  or  a  committee  may  inspect  the 
condition  and  obtain  information  from  those  who  know  about 
it.  They  would  repeat  the  work  of  the  health  officer  and  check 
up  his  observations. 

The  second  method  of  investigation  by  a  board  of  health  is 
to  summon  the  offender  before  it  and  discuss  the  matter  with 
him.  The  legal  status  of  such  an  examination  is  that  it  affords 
the  offender  an  opportunity  to  explain  his  side  of  the  case  and 
show  cause  why  an  order  to  correct  the  condition  should  not  be 
issued.  Such  an  examination  and  discussion  is  similar  to  the 
action  of  a  health  officer  in  calling  upon  an  offender,  but  it 
has  the  weight  and  dignity  of  a  formal  action  by  an  official 
body.  It  usually  results  in  the  correction  of  the  condition  of  the 
offender. 

The  third  method  of  conducting  an  investigation  by  a  board 
of  health  is  a  formal  hearing.  A  board  of  health  in  New  York 
State  has  the  power  to  subpena  witnesses,  and  to  examine  them 
under  oath  according  to  the  rules  of  court  procedure  (Public 
Health  Law,  Sec.  21). 

After  a  board  of  health  has  completed  its  investigation,  it 
must  make  a  decision  whether  or  not  the  condition  affects  the 
health  of  a  considerable  number  of  persons,  or  is  a  violation  of 
a  law  or  sanitary  code.  This  act  of  decision  by  a  board  of 
health  is  similar  in  nature  to  that  which  is  made  by  the  health 
officer.        ; 

If  the  board  decides  that  the  condition  requires  a  remedy, 
its  next  step  is  to  issue  an  order  that  the  correction  be  carried 
out.  An  order  is  analogous  to  the  information  and  notice  that 
is  given  by  a  health  officer  to  an  offender.  It  differs  from  a 
notice  in  two  important  respects:  first,  it  is  official,  and  is  author- 
ized by  law;  and  second,  disobedience  of  it  is  punishable  (New 
York  Public  Health  Law,  Sec.  21;  and  Penal  Law,  Sec.  1740). 
An  order  has  the  force  of  law,  and  is  practically  a  special  law 
made  to  fit  an  individual  condition  that  already  exists. 

Making  an  investigation,  forming  a  decision,  and  issuing  an 
order  are  official  actions  of  a  board  of  health,  but  they  do  not 
have  legal  force  unless  they  are  recorded  in  the  minutes  of  the 


78  THE    HEALTH    OFFICER 

board  of  health,  A  mistake  or  omission  in  the  minutes  may 
render  all  the  proceedings  of  no  effect. 

If  an  order  of  a  board  of  health  is  disregarded,  the  offender  is 
liable  to  punisliment  for  disobedience;  but  the  usual  custom  is 
not  to  exact  punishment  for  the  disobedience,  but  to  bring  suit 
for  damages  or  punishment  on  account  of  the  continued  main- 
tenance of  the  condition. 

An  order  of  a  board  of  health  is  in  one  of  three  forms.  The 
first  form  is  that  for  the  summary  correction  of  a  condition.  It 
is  usually  issued  to  the  health  officer  directing  him  to  employ 
the  necessary  persons  and  means  to  carry  out  the  remedy.  The 
statutes  of  New  York  State  (Public  Health  Law,  Sec.  21)  au- 
thorize the  board  of  health  to  issue  warrants  to  any  police 
officer  of  the  municipality  to  apprehend  and  remove  such  persons 
as  cannot  otherwise  be  subjected  to  its  orders  or  regulations; 
and  to  the  sheriff"  of  the  county  to  lend  the  aid  of  the  county  if 
necessary.  This  clause  is  the  source  of  the  authority  which  a 
health  officer  exercises  in  maintaining  a  forcible  quarantine  in 
a  contagious  disease  and  in  doing  other  summary  acts. 

The  second  form  of  order  is  that  which  is  issued  directly  to 
the  offender.  It  sets  forth  the  unsanitary  condition,  orders  him 
to  correct  it  within  a  specified  time,  and  informs  him  that 
legal  action  will  be  taken  against  him  if  he  fails  to  obey  the  order. 
An  offender  must  be  served  personally  with  a  copy  of  the  order 
so  that  he  may  know  what  is  required  of  him.  The  person 
serving  the  order  must  make  an  affidavit  that  he  served  it,  in 
order  that  the  board  of  health  may  be  able  to  prove  that  it  com- 
plied with  all  the  necessary  steps. 

The  third  form  of  order  by  the  board  of  health  is  that  direct- 
ing the  health  officer,  or  the  counsel  for  the  board,  or  some  other 
ofticer  to  begin  a  suit  at  law  in  order  to  secure  the  correction  of 
an  unhealthful  condition.  It  is  the  custom  to  have  the  health 
officer  do  it,  but  legally  the  counsel  for  the  board  should  do  it. 

Court  Action. — A  suit  at  law  is  the  last  resort  of  an  efficient 
health  officer,  and  he  will  seldom  start  one  or  threaten  to  do  so. 
A  law  suit  takes  a  public  health  matter  out  of  the  hands  of  health 
experts  and  places  it  in  the  control  of  judges  and  jurymen  who 
are  laymen,  and  are  usually  imbued  with  the  medical  ideas  of 
a  generation  ago.  The  result  of  a  law  suit  is  uncertain,  and  de- 
pends largely  on  the  state  of  public  sentiment  toward  the  matter 
in  dispute.  If  a  person  is  disobedient,  it  is  often  because  a  group 
of  people  encourage  him  in  his  attitude,  and  make  him  feel  that 
he  has  public  sentiment  on  his  side. 

The  basis  of  any  suit  is  the  violation  of  a  law  or  local  ordi- 
nance.    It  is  necessary  that  a  health  officer  be  able  to  point  to 


STANDARD   PROCEDURES  79 

the  exact  section  of  a  statute  law  or  to  a  regulation  of  a  local 
code  that  has  been  violated.  If  he  cannot  find  one  which  aj)i)lies 
to  the  condition,  there  will  be  no  use  in  starting  a  suit,  for  the 
court  will  be  compelled  to  dismiss  the  action. 

The  ordinary  court  actions  brought  by  health  officers  are 
either  criminal  or  civil.  Some  laws  and  codes  specifiy  that  a 
violation  of  them  will  constitute  a  misdemeanor,  and  others  make 
it  a  civil  offense.  A  misdemeanor  is  a  criminal  offense.  It  im- 
plies moral  misconduct,  and  is  punishable  by  a  fine  or  imprison- 
ment. A  civil  offense  does  not  imply  moral  misconduct,  and  a 
judgment  against  a  defendant  is  rendered  as  a  restitution  of 
money  for  damages.  Whether  a  violation  constitutes  a  misde- 
meanor or  a  civil  offense  depends  on  the  words  of  the  law  or  code. 

A  health  officer  begins  a  criminal  action  by  making  a  sworn 
statement,  called  a  deposition,  before  a  judge,  naming  the  of- 
fender and  the  exact  nature  of  the  offense,  the  municipality  and 
county  in  which  the  offense  was  committed,  and  the  date,  and 
the  section  of  law  or  code  that  is  violated.  The  judge  then 
issues  a  warrant  to  a  policeman  ordering  him  to  arrest  the 
offender  and  bring  him  to  court  at  once. 

A  health  officer  begins  a  civil  action  by  going  before  a  judge 
and  making  a  sworn  statement  of  the  facts,  as  in  a  criminal 
action.  The  judge  then  issues  a  summons  ordering  the  offender 
to  appear  in  the  court  at  a  specified  time,  which  in  New  York 
State  must  be  at  least  six  days  after  the  summons  is  issued. 

A  civil  action  is  a  much  slower  procedure  than  a  criminal 
one.  When  a  condition  requires  immediate  action,  a  health 
officer  can  usually  find  some  ground  for  bringing  a  criminal 
action,  and  thereby  hasten  the  settlement  of  the  matter, 

A  court  action  is  a  legal  matter,  and  a  health  officer  may 
justly  insist  that  the  board  of  health  employ  a  lawyer  to  take 
charge  of  the  case  from  its  beginning. 

A  health  officer  is  responsible  for  the  evidence  in  a  public 
health  case.  If  his  inspections  and  investigations  have  been 
complete  and  he  has  written  records  of  them,  he  can  go  to  court 
with  confidence.  But  if  he  has  omitted  any  important  part  of 
his  investigation,  or  is  uncertain  in  his  knowledge,  the  opposing 
lawyer  will  probably  be  able  to  show  that  the  evidence  is  in- 
sufficient to  convict.  A  court  action  will  be  futile  unless  a 
health  officer  is  sure  of  every  step  which  he  has  taken  previous 
to  bringing  the  action. 

The  judgment  in  a  law  suit  over  a  public  health  matter  does 
not  order  an  offender  to  remedy  a  condition.  It  merely  imposes 
a  penalty  for  the  past  existence  of  the  condition.  But  if  the 
offense  is  continued,  the  health  officer  may  bring  a  new  action 


80  THE   HEALTH    OFFICER 

for  each  day  on  which  the  unsanitary  condition  exists  until  the 
ofifender  corrects  it. 

Injunction. — If  an  unhealthful  condition  is  continued,  a  health 
officer  may  obtain  an  injunction.  This  is  a  court  order  that  a 
person  shall  cease  from  performing  a  designated  act.  Obtain- 
ing an  injunction  is  a  complicated  legal  process,  and  is  used  only 
for  the  relief  of  important  conditions  to  which  no  specific  law 
applies. 


CHAPTER  IX 

LOCAL  SANITARY  CODE 

Relation  to  State  Law. — A  large  measure  of  home  rule  is 
essential  in  public  health  work.  A  community  must  develop 
its  own  strength  for  resistance  to  disease  and  physical  decay. 
An  ideal  condition  in  public  health  is  that  local  departments 
shall  do  their  work  so  well  that  the  only  function  of  the  state 
department  is  to  act  as  a  clearing  house  for  collecting  and  dis- 
tributing information.  A  near  approach  to  that  ideal  is  that 
each  local  department  of  health  shall  develop  the  details  of  its 
own  work  along  the  lines  which  the  state  department  indicates 
in  a  general  way. 

The  powers  of  governing  bodies  of  local  municipalities  are 
those  which  have  been  delegated  to  them  by  state  legislatures. 
Every  state  allows  its  legislature  to  delegate  some  of  its  powers 
to  the  local  municipalities — the  towns,  villages,  cities,  and  coun- 
ties. Local  governing  boards  may  adopt  rules  and  regulations 
dealing  with  any  phase  of  public  health. 

Method  of  Adoption. — It  is  the  duty  as  well  as  the  privilege 
of  every  local  board  of  health  to  take  enough  interest  in  public 
health  matters  to  enact  a  set  of  local  ordinances  for  the  control 
of  local  health  conditions,  and  to  keep  the  regulations  abreast 
of  the  constant  progress  in  hygiene  and  sanitation.  The  legal 
method  by  which  a  board  of  health  adopts  a  sanitary  code  is 
usually  that  by  which  other  local  boards  adopt  rules  and  laws. 
The  steps  vary  in  the  several  states,  and  whatever  they  are  they 
must  be  followed  in  order  to  make  the  ordinances  legal.  The 
steps  in  New  York  State  are  simply  that  the  board  shall  pass 
the  ordinances  and  publish  them.  No  method  of  publication  is 
prescribed,  and  posting  the  ordinance  on  a  bulletin  board  in  a 
pubhc  place  would  meet  the  requirements  of  the  law.  It  is  a 
good  plan  to  have  printed  copies  of  the  ordinances  made  for 
free  distribution  to  the  public  and  to  offenders. 

Local  officials  sometimes  confuse  orders  and  ordinances. 
An  order  deals  with  a  single  specific  past  offense,  and  is  not  bind- 
ing unless  it  has  been  served  upon  the  offender  personally.  An 
ordinance  does  not  apply  to  offences  committed  before  it  was 
passed,  but  deals  only  with  future  offenses.  It  applies  to  any 
number  of  offenders,  and  publication  of  it  is  sufficient  to  make  it 
binding  upon  all  persons. 

6  8i 


82  THE   HEALTH    OFFICER 

Relation  of  a  Sanitary  Code  to  Statute  Law. — A  department 
of  health,  either  state  or  local,  may  enact  a  sanitary  code  dealing 
with  almost  any  matter  provided  it  complies  with  two  conditions: 
first,  that  the  matter  affects  public  health;  second,  that  the  ordi- 
nance does  not  conflict  with  a  statute  law  or  a  regulation  made 
by  a  higher  authority.  The  statute  laws  are  usually  general. 
They  outline  the  form  of  organization  of  the  departments  of 
health  and  indicate  the  general  scope  of  the  subjects  with  which 
the  departments  may  deal.  A  sanitary  code  specifies  the  man- 
ner of  carrying  out  the  laws.  For  example,  the  Public  Health 
Law  of  New  York  State,  Sec.  25,  provides  that  a  local  board  of 
health  shall  exercise  "Proper  and  vigilant  medical  inspection 
and  control  of  all  persons  and  things  infected  with  or  exposed  to 
communicable  diseases."  The  State  Sanitary  Code  outlines 
standard  methods  of  carrying  on  the  inspection  and  control. 
The  statute  law  is  sufficient  authority  by  which  a  local  board 
makes  rules  and  regulations  concerning  the  quarantine  of  cases 
of  contagious  diseases,  the  control  of  sewage,  water-supplies, 
and  milk,  and  almost  any  other  detail  of  controlling  commu- 
nicable diseases. 

A  statute  law  is  enacted  by  laymen,  and  is  designed  to  be 
permanent.  A  sanitary  code  is  enacted  by  experts,  and  may  be 
easily  changed  and  adapted  to  progress  in  the  sciences  of  medi- 
cine and  sanitation.  A  code  which  is  up  to  date  today  may  be 
antiquated  within  five  years  unless  it  is  frequently  revised  and 
standardized.  A  sanitary  code  or  other  authoritative  statement 
of  standard  methods  of  procedure  is  necessary  in  carrying  on 
any  line  of  public  health  work. 

Relation  of  Local  Code  to  State  Code. — A  state  sanitary  code 
deals  with  conditions  which  are  of  universal  application  through- 
out the  state,  leaving  matters  of  local  interest  to  be  included  in 
the  local  code.  For  example.  Chapter  II  of  the  Sanitary  Code 
of  New  York  State  enumerates  the  communicable  diseases  which 
health  officers  are  to  control.  It  specifies  the  manner  in  which 
the  diseases  are  to  be  reported,  and  how  cases  are  to  be  quaran- 
tined and  their  rooms  disinfected.  The  state  code  fixes  minimum 
standards  which  the  local  boards  may  make  more  stringent  if 
they  choose.  For  example,  the  State  Code  requires  an  isolation 
of  seven  days  in  measles,  but  the  local  board  may  make  the 
isolation  period  two  weeks  or  more. 

New  York  State  has  a  sanitary  code  whose  provisions  apply 
equally  well  to  a  rural  district  and  to  a  city.  It  is,  in  effect,  a 
part  of  the  local  sanitary  code  of  each  municipality.  It  and  the 
health  ordinances  enacted  by  his  local  board  of  health  constitute 
the  code  under  which  a  health  officer  must  act. 


LOCAL   SANITARY   CODE  83 

Essentials  of  a  Code. — A  sanitary  code  must  fulfil  two  es- 
sential conditions:  First,  its  provisions  must  be  reasonable. 
They  must  be  in  accordance  with  standard  medical  practice, 
and  their  requirements  must  not  be  unduly  burdensome  or 
arbitrary.  It  would  be  unreasonable,  for  example,  to  require 
a  strict  quarantine  for  a  case  of  typhoid  fever,  or  to  specify 
the  use  of  a  particular  brand  of  chlorid  of  lime  as  a  disin- 
fectant. 

A  second  essential  condition  of  a  sanitary  ordinance  is  that 
its  application  must  be  uniform  throughout  the  district  over 
which  the  enacting  board  has  jurisdiction.  For  example,  there 
is  doubt  that  a  board  of  health  has  a  legal  right  to  establish  a 
restricted  area  within  which  pigs  shall  not  be  kept.  But  some 
method  can  usually  be  devised  to  accompHsh  a  desired  end 
legally.  If  a  board,  for  example,  should  pass  an  ordinance  that 
no  pigs  should  be  kept  within  500  feet  of  a  dwelling,  the  effect 
would  be  to  establish  a  restricted  area  in  the  built-up  portions  of 
a  village  or  city,  and  yet  the  ordinance  would  be  of  uniform 
application. 

Wording. — ^A  local  sanitary  code  is  designed  for  the  ignorant 
and  stupid  as  well  as  for  the  educated.  It  informs  the  people 
what  they  are  expected  to  do  in  public  health  work.  It  is  im- 
portant that  it  be  cast  in  simple,  untechnical  language  which 
the  people  can  understand  readily.  The  primary  object  of  a 
code  is  not  to  be  a  guide  for  judging  lawbreakers  in  court,  but 
to  educate  people  of  all  classes  in  standard  methods  of  sanitary 
and  hygienic  procedure.  The  code  is  a  text-book  in  these 
matters,  and  the  simpler  and  clearer  its  form,  the  more  useful 
it  will  be.  An  ordinance  that  is  lengthy  and  is  complicated  in 
grammatical  structure  is  an  excellent  mark  for  attack  by  a  shrewd 
lawyer;  while  the  meaning  of  one  that  is  short  and  concise  is 
evident  even  to  ignorant  persons. 

The  educational  value  of  an  ordinance  depends  largely  upon 
the  expression  which  receives  the  emphasis.  The  most  emphatic 
position  in  a  sentence  or  paragraph  is  at  its  beginnning.  It  is 
well  to  begin  an  ordinance  with  the  leading  thought  or  with  an 
expression  of  the  first  importance.  For  example,  if  a  board 
wishes  to  prevent  the  exposure  of  food  on  sidewalks  and  in  open 
stalls,  it  might  draft  an  ordinance  as  follows:  "All  food  sold  or 
offered  for  sale  on  a  sidewalk,  or  in  an  open  stall,  shall  be  kept 
protected  from  dust  and  flies."  Here  the  emphatic  statement  is 
at  the  end  and  is  likely  to  excite  only  a  mild  interest  in  the  mind 
of  an  ignorant  person.  A  more  forcible  wording  is  as  follows: 
"No  person  shall  sell  or  offer  for  sale  any  food  that  has  been  ex- 
posed to  dust  and  flies  on  a  sidewalk  or  open  stall."     This  form 


84  THE   HEALTH    OFFICER 

emphasizes  the  fact  that  food  cannot  be  sold,  and  the  reader  is 
at  once  curious  to  know  why  not. 

Subjects  of  Ordinances. — An  ideal  sanitary  code  will  deal 
with  every  condition  that  a  health  officer  is  likely  to  meet  in 
his  jurisdiction.  It  will  be  a  guide  for  both  the  health  officer 
and  the  people,  and  will  indicate  the  scope  of  the  work  which 
the  health  officer  is  expected  to  perform.  It  will  enable  a  health 
officer  to  point  to  a  definite  source  of  authority  for  each  act.  It 
will  relieve  him  of  the  charge  of  partiality  in  dealing  with  un- 
reasonable people,  for  he  can  show  that  the  board  of  health 
has  anticipated  his  decisions  for  him. 

An  ideal  code  will  also  exclude  regulations  dealing  with 
trivial  matters.  A  useless  regulation  will  belittle  a  whole  code, 
for  the  people  may  not  discriminate  between  the  useful  and  the 
useless. 

An  ideal  code  will  deal  only  with  subjects  which  have  a  direct 
relation  to  health.  The  older  codes  dealt  with  many  matters 
which  were  formerly  supposed  to  affect  health,  but  which  are 
now  known  to  be  matters  of  decency,  and  to  affect  property 
values  rather  than  man  himself.  The  control  of  street  dust, 
rubbish  heaps,  and  ash  piles  does  not  properly  belong  to  the 
health  department.  Such  conditions  as  these  may  be  dealt 
with  under  a  brief  regulation  dealing  with  decaying  substances. 
Still,  regulations  on  such  matters  are  often  useful  in  an  unpro- 
gressive  community,  for  it  enables  the  progressive  element  in 
the  municipality  to  carry  on  a  clean-up  campaign  which  may 
indirectly  bear  fruit  in  securing  sanitation  along  more  useful 
lines. 

The  consideration  and  adoption  of  a  modern  sanitary  code 
will  help  to  educate  a  board  of  health  in  sanitary  matters.  A 
code  puts  health  matters  before  a  board  in  a  concrete  form.  It 
is  a  catalog  of  the  varied  activities  of  a  health  officer,  and  indi- 
cates the  comparative  values  of  different  phases  of  his  work. 
It  is  a  guide  to  the  board  in  estimating  the  amount  of  work  which 
a  health  officer  is  expected  to  do,  and  a  standard  by  which  it 
may  judge  him  in  the  performance  of  his  work. 

Rules  of  Procedure. — Boards  of  health  of  the  larger  cities 
issue  handbooks  of  procedure  for  the  various  bureaus  contain- 
ing the  uniform  rules  of  procedure  which  the  employees  of  the 
department  of  health  are  to  follow  in  the  discharge  of  their 
duties.  The  rules  of  procedure  which  the  health  officers  of 
towns,  villages,  and  the  smaller  cities  follow  in  the  discharge  of 
their  technical  duties  are  often  contained  in  instructions  and 
circulars  of  information  sent  out  by  the  state  departments  of 
health.     A  sanitary  code  is  designed  for  the  instruction  of  per- 


LOCAL  SANITARY   CODE  85 

sons  outside  of  the  department  of  health,  but  it  may  projierly 
include  the  general  rules  of  procedure  which  legalize  the  acts  of 
a  health  officer  in  his  dealings  with  physicians  and  the  people 
generally. 

A  MODEL  CODE 

Every  municipality  needs  a  sanitary  code  for  the  guidance 
of  the  health  officer,  the  board  of  health,  and  the  public.  It 
makes  little  difference  whether  it  is  adopted  entirely  by  the  state 
department  of  health,  or  entirely  by  the  local  board  of  health, 
or  partly  by  each.  If  there  is  a  state  code,  its  regulations  will 
be  binding  if  they  are  not  in  the  local  code.  The  remainder  of 
this  chapter  will  be  devoted  to  examples  of  regulations  for  a 
local  code. 

Title. — The  sanitary  code  of  the — ■■ 

of — ,  adopted  by  the  board  of  health 

on ■ ,  pursuant  to  Section of  the 

public  health  law. 

Regulation  — . — ^Any  violation  of  any  section  of  this  sanitary 

code  shall  subject  the  offender  to  a  penalty  of  % to  be  sued 

for  and  recovered  by  and  for  the  benefit  of  the of . 

(A  code  is  not  binding  unless  a  penalty  for  its  violation  is 
specified.  A  violation  may  be  either  a  misdemeanor  or  a  civil 
offense,  according  to  the  wording  of  the  statute  law  under 
whose  authority  the  code  is  enacted.  The  New  York  State  law 
allows  the  State  Department  of  Health  to  declare  a  violation 
of  the  State  Code  a  misdemeanor,  but  the  local  department  can 
impose  only  a  civil  penalty.  It  is  well  to  fiLx  the  penalty  at  a 
sum  so  small  that  the  offender  may  be  tried  in  the  lowest  court. 
This  sum  in  New  York  State  is  $50.) 

Regulation  — . — Regular  meetings  of  the  board  of  health 

shall  be  held  on  the  in  .     The 

president  or  any  two  members  shall  call  special  meetings  when- 
ever an  emergency  arises  in  which  the  health  officer  requires  the 
assistance  of  the  board.  Each  member  may  act  as  a  committee 
of  the  board  of  health  to  make  inspections  and  investigations, 
and  to  consult  with  the  health  officer  and  assist  him  in  handhng 
matters  of  a  legal  or  financial  nature  whenever  the  health  officer 
shall  require  his  assistance. 

Regulation  — . — In  addition  to  the  duties  imposed  upon  him 
by  the  public  health  law  and  the  state  sanitary  code,  the  health 
ojSicer  shall  perform  the  following  duties : 

1,  Execute  and  enforce  the  regulations  and  orders  which 
may  be  enacted  or  issued  by  the  board  of  health. 

2.  Keep  himself  informed  regarding  the  progress  in  the 
sciences  of  sanitation  and  public  health  work. 


86  THE   HEALTH   OFFICER 

3.  Preserve  and  file  all  ofiicial  information  and  instructions 
which  he  receives  from  the  State  Department  of  Health  and 
other  superior  official  bodies,  and  carry  out  the  instructions  to 
the  best  of  his  ability. 

4.  Keep  a  record  of  his  official  acts,  and  make  a  monthly 
report  to  the  board  of  health. 

5.  Keep  supplies  of  antitoxins,  serums,  culture- tubes,  and 
other  laboratory  products  sent  from  the  Laboratory  of  the  State 
Department  of  Health,  and  assist  and  instruct  physicians  in 
their  use. 

6.  He  may  give  full  information  to  the  public  regarding  the 
existence  of  communicable  diseases  within  his  jurisdiction,  ex- 
cept that  which  is  held  by  law  to  be  of  a  confidential  nature. 

7.  When  an  emergency  arises  requiring  inmiediate  action, 
he  shall  consult  some  member  of  the  board  of  health,  if  possible, 
before  taking  action,  and  shall  report  his  action  to  the  board  of 
health  has  soon  as  possible  thereafter. 

Method  of  Procedure 

Regulation  — . — When  a  health  officer  receives  a  complaint 
regarding  a  condition,  person,  or  thing  which  is  likely  to  aft'ect 
health,  or  when  the  probable  existence  of  such  a  condition,  per- 
son, or  thing  comes  to  his  attention,  he  shall  at  once  take  action 
as  follows: 

1.  Make  an  immediate  and  thorough  investigation. 

2.  Decide  (a)  whether  or  not  the  condition,  person,  or  thing 
may  be  a  danger  to  health  or  life;  and  (b)  whether  or  not  it  af- 
fects a  considerable  number  of  persons. 

3.  If  it  affects  the  health  or  lives  of  a  considerable  number  of 
persons,  the  health  officer  shall  serve  or  cause  to  be  served  upon 
the  oft'ending  party  a  written  notice  which  shall 

(a)  Describe  the  unhealthful  conditions. 

(b)  Suggest  the  remedy. 

(c)  State  the  period  of  time  within  which  the  remedy  shall 

be  carried  out. 

4.  Keep  himself  informed  regarding  the  condition,  person, 
or  thing. 

5.  If  he  is  unable  to  secure  a  remedy,  he  shall  report  his 
action  to  the  board  of  health  and  request  its  assistance. 

Regulation  — . — When  a  health  officer  or  his  representative 
makes  an  investigation  or  inspection,  he  shall  proceed  as  follows: 

1.  Visit  the  locality,  and,  if  possible,  talk  over  the  conditions 
with  the  persons  who  have  knowledge  of  or  are  responsible  for 
them. 


LOCAL   SANITARY   CODE  87 

2.  Take  samples  and  cultures,  if  necessary,  and  transmit 
them  to  an  authorized  laboratory  for  examination. 

3.  Make  notes  at  once  describing  the  conditions  accurately 
and  stating  the  place,  date,  and  time  of  making  the  investiga- 
tion or  inspection. 

4.  Inform  the  responsible  parties  of  his  findings,  and  explain 
the  nature  of  the  conditions,  and  the  remedy  if  one  is  needed. 

5.  On  returning  to  the  office  make  a  record  of  his  action. 

Nuisances 

Regulation  — . — When  a  health  officer  shall  receive  a  com- 
plaint of  a  condition  which  is  commonly  called  a  nuisance  and 
which  is  not  specifically  covered  by  any  section  of  this  code 
or  of  the  State  Sanitary  Code,  or  by  any  statute  law,  or  when- 
ever the  probable  existence  of  such  a  condition  comes  to  his 
attention,  he  shall  at  once  take  action  according  to  the  method 
prescribed  by  this  code. 

Regulation  — . — The  board  of  health  shall  take  formal  action 
regarding  a  condition,  person,  or  thing  that  may  endanger  health 
when 

{a)  The  health  officer  reports  that  he  is  unable  to  secure  an 
adequate  remedy;  or 

{h)  The  health  officer  fails  or  refuses  to  act;  or 

(c)  Either  the  complainants  or  the  party  against  whom  com- 
plaint is  made  appeals  to  the  board;  or 

{d)  The  state  commissioner  of  health  or  other  higher  au- 
thority requests  it  to  act. 

The  action  which  the  board  of  health  shall  take  shall  be  as 
follows : 

{a)  Make  a  formal  investigation  either 

(1)  By  a  personal  inspection  made  by  the  individual  mem- 

bers or  a  committee  of  the  board;  or 

(2)  By  an  examination  of  the  person  against  whom  the 

complaint  is  made   after  he  shall  have  been  sum- 
moned before  the  board;  or 

(3)  By  a  formal  hearing  conducted  after  due  notice  and 

according  to  law. 
{h)  Make  a  formal  decision  whether  or  not  the  condition, 
person,  or  thing  may  endanger  the  health  of  a  considerable 
number  of  persons ;  and 

(c)  If  the  condition,  person,  or  thing  endangers  the  health 
of  a  considerable  number  of  persons,  the  board  shall  either 

(1)  Order  the  health  officers  to  take  summary  action  to 
remedy  it;  or 


88  THE  HEALTH   OFFICER 

(2)  Cause  a  written  order  to  be  served  on  the  offender, 

stating  the  remedy  and  the  period  of  time  within 
which  it  shall  be  applied,  and  authorizing  the  health 
officer  or  the  counsel  for  the  board  to  institute  legal 
•  proceedings  against  the  offender  in  case  the  orders 
are  not  carried  out;  or 

(3)  Order  the  health  officer  or  the  counsel  for  the  board 

to  institute  legal  proceedings  against  the  off'ender  at 

once. 
Regulation  — . — The  health  officer  is  hereby  authorized  to 
take  summary  action  when  a  condition,  person,  or  thing  is  one 
in  which  the  germs  of  a  communicable  disease  are  known  to 
be  directly  involved  and  in  which  there  is  immediate  danger 
that  the  germs  may  be  transmitted  to  human  beings. 

Communicable  Diseases 

The  regulations  regarding  communicable  diseases  are  among 
the  most  important  in  a  code.  They  embrace  the  following 
subjects : 

1.  A  list  of  diseases  to  be  reported. 

2.  Who  shall  report  them,  and  how. 

3.  Taking  cultures  in  suspicious  cases. 

4.  Enforcing  isolation,  quarantine,  and  disinfection. 

5.  Placarding  infected  premises. 

6.  Exclusion  from  school  and  return  of  pupils. 

7.  Removal  to  a  contagious  disease  hospital. 

8.  Relation  to  milk  and  other  foods. 

All  these  points  are  covered  in  a  model  manner,  and  at  con- 
siderable length,  in  the  Sanitary  Code  of  New  York  State.  It  is 
a  good  plan  for  a  board  of  health  to  enact  these  regulations,  and 
also  to  adopt  additional  ones  authorizing  the  health  officer  to 
act  in  mild  or  suspicious  cases,  and  specifying  the  exact  manner 
of  conducting  an  isolation  or  quarantine.  The  following  addi- 
tional regulations  are  suggested: 

Regulation  — . — The  health  officer  shall  exercise  diligence  in 
the  discovery  and  control  of  cases  of  communicable  diseases. 
Whenever  the  rumor  or  report  of  the  probable  existence  of  a 
case  of  communicable  disease  comes  to  him  from  a  source  that  is 
presumably  rehable,  he  shall  investigate  the  report,  and  if  no 
physician  is  in  attendance,  he  shall  visit  and  examine  the  sus- 
pected person.  If  he  finds  the  disease  to  be  one  which  is 
reportable  under  the  code,  he  shall  take  the  necessary  measures 
for  its  control. 

Regulation  — . — If  an  epidemic  is  prevalent,  every  person 


LOCAL   SANITARY   CODE  89 

who  has  well-marked  signs  that  are  usually  associated  with  the 
disease  that  is  prevailing  shall  be  excluded  from  school,  Sunday- 
school,  stores,  and  other  places  of  public  gathering  until  the 
nature  of  the  disease  is  determined. 

Regulation  — . — When  there  is  doubt  regarding  the  nature 
of  a  disease  that  is  presumably  communicable,  the  health  officer 
shall  examine  the  suspected  person  and  shall  consult  with  the 
family  physician  if  possible,  and  the  diagnosis  of  the  health 
ofhcer  shall  be  the  official  diagnosis. 

Regulation  — . — Every  person  who  is  a  carrier  of  disease 
germs  shall  be  subject  to  the  following  rules  and  regulations : 

1.  They  or  those  persons  who  are  responsible  for  their  care 
and  welfare  shall  truthfully  inform  the  health  officer  concerning 
their  present  condition,  and  the  history  of  any  recent  sickness. 

2.  Except  with  the  consent  of  the  health  officer,  they  shall 
not  attend  any  school,  Sunday  school,  church,  theater,  lecture 
hall,  or  other  public  meeting  place,  or  be  present  at  any  gather- 
ing where  they  may  come  in  contact  with  children. 

3.  Neither  they  nor  their  attendants  shall  engage  in  any 
occupation  in  which  they  handle  food. 

4.  They  shall  follow  the  instructions  of  the  health  ofi&cer 
regarding  coming  in  contact  with  other  persons. 

Regulation  — . — When  a  physician  reports  a  case  of  com- 
municable disease,  he  shall  inform  the  health  officer  regarding 
the  measures  of  control  which  he  has  instituted,  and  whether 
or  not  the  patient  and  those  associated  with  him  will  submit  to 
the  control.  If  the  measures  are  insufficient  or  ineffective  for 
preventing  the  spread  of  the  disease,  the  health  officer  shall 
visit  the  house  of  the  diseased  person  and  shall  institute  the 
necessary  measures  for  control.  He  may  employ  guards  and 
watchers  if  necessary  in  order  to  enforce  the  control. 

Regulation  — . — All  persons  afflicted  with  smallpox,  cholera, 
typhus  fever,  or  plague  shall  be  subject  to  the  folowing  rules 
for  their  quarantine  and  control : 

1.  The  patient  shall  be  isolated  in  a  house,  and  no  one  shall 
enter  or  leave  the  house  except  with  the  health  officer's  permis- 
sion, which  shall  be  given  only  to  the  necessary  attendants. 

2.  Other  occupants  of  the  house  and  members  of  the  house- 
hold may  leave  the  premises  as  soon  as  the  disease  is  discovered, 
provided  they  comply  with  the  regulations  and  instructions  of 
the  State  Department  of  Health  and  the  requirements  of  the 
health  officer. 

Regulation  — . — ^All  persons  afflicted  with  diphtheria,  cere- 
brospinal meningitis,  measles,  scarlet  fever,  and  poliomyehtis 
shall  be  subject  to  the  following  rules  for  their  isolation : 


90  THE  HEALTH   OFFICER 

1.  The  patient  shall  be  isolated  in  a  room  that  is  shut  oflf  from 
the  rest  of  the  house,  and  no  person  except  the  necessary  attend- 
ants shall  enter  the  room. 

2.  All  excretions  of  the  patient  shall  be  disinfected  in  a  man- 
ner approved  by  the  health  officer,  and  in  accordance  with  the 
instructions  of  the  State  Department  of  Health. 

3.  The  attendants  shall  sleep  and  eat  apart  from  the  other 
members  of  the  household,  and  shall  not  mingle  with  them. 
They  shall  at  all  times  keep  their  clothing  and  persons  clean  and 
disinfected.  They  shall  not  leave  the  premises  except  with  the 
pemiission  of  the  health  officer  and  after  following  his  direc- 
tions for  cleansing  and  disinfecting  their  clothing  and  persons. 

4.  Healthy  adult  members  of  the  household  may  go  about 
their  usual  vocations,  provided  they  do  not  handle  food  or  come 
in  close  contact  with  children. 

5.  If  any  member  of  the  household  violates  these  rules,  the 
health  officer  may  impose  a  complete  quarantine  of  the  house 
as  in  Regulation  No.  —  (relating  to  smallpox). 

6.  If  a  house  is  arranged  for  two  or  more  families,  and  the 
sets  of  apartments  are  completely  shut  off  from  one  another, 
the  health  officer  may  omit  to  impose  restrictions  on  the  members 
of  the  households  in  which  there  is  no  sickness. 

Regulation  — . — All  persons  afflicted  with  chicken-pox,  Ger- 
man measles,  mumps,  or  whooping-cough  shall  remain  at  home, 
and  shall  not  leave  their  premises  except  by  permission  of  the 
health  officer,  and  no  visitor  w^ho  has  not  had  the  disease  shall 
be  allowed  to  enter  the  house. 

Regulation  — . — The  periods  of  quarantine,  isolation,  control, 
and  observation  of  a  person  who  has  or  is  suspected  of  having  a 
communicable  disease  shall  be  those  prescribed  from  time  to  time 
by  the  State  Department  of  Health. 

Diseased  Animals 

Regulation  — . — The  health  officer  shall  carry  out  the  pro- 
visions of  the  Agricultural  Law  relating  to  diseased  animals, 
except  those  which  impose  duties  upon  some  other  officer  or  a 
veterinarian. 

Regulation  — . — Every  owner  or  custodian  of  any  animal 
afflicted  with  glanders,  anthrax,  rabies,  trichinosis,  foot-and- 
mouth  disease,  tuberculosis,  or  other  disease  which  may  be 
transmitted  to  human  beings,  and  ever}^  veterinarian  treating 
such  animal,  shall  report  the  existence  of  the  disease  to  the  health 
offlcer.  The  health  officer  shall  cause  the  animal  to  be  isolated, 
and  to  be  given  such  care  as  may  be  necessary  to  prevent  the 


LOCAL   SANITARY   CODE  91 

transmission  of  the  disease  to  other  animals  or  to  human  beings. 
No  animal  afflicted  with  any  of  these  diseases  shall  be  allowed 
upon  any  highway  or  in  any  public  place.  If  an  animal  having 
such  a  disease  dies,  its  body  shall  be  buried  under  the  direction 
of  the  health  officer  in  such  a  manner  that  the  disease  shall  be 
prevented  from  spreading. 

Regulation  — . — No  meat,  milk,  or  other  product  from  an 
animal  that  has  a  disease  which  may  be  transmitted  to  a  human 
being  shall  be  offered  for  sale,  or  used  as  food  for  animals  or 
human  beings,  except  with  the  permission  of  the  health  officer. 

Regulation  - — . — The  health  officer  may  authorize  the  destruc- 
tion and  burial  of  any  diseased  animal  that  is  found  astray  in 
any  highway  or  in  any  public  place. 

Milk 

A  board  of  health  may  require  permits  for  the  sale  of  milk, 
specify  the  conditions  under  which  milk  may  be  produced  and 
dispensed,  fix  the  grades  of  milk,  and  institute  a  system  of  milk 
inspection.  These  points  are  clearly  covered  in  the  Sanitary 
Code  of  New  York  State.  Additional  regulations  may  be  de- 
sirable, as  follows: 

Regulation  — . — The  health  officer  shall  carry  out  the  provi- 
sions of  the  public  health  law,  the  State  Sanitary  Code,  and  the 
official  instructions  and  decisions  of  the  State  Department  of 
Health,  relating  to  the  production  and  sale  of  milk  and  milk 
products.  He  shall  also  carry  out  the  provisions  of  the  Agri- 
cultural Law  relating  to  milk,  milk  products,  and  cattle,  except 
those  which  impose  duties  upon  some  other  officer  or  a  veter- 
inarian. 

Regulation  — , — No  person  who  has  a  sore  throat  or  a  fever, 
or  who  has  any  other  usual  sign  of  a  communicable  disease,  or 
who  is  a  carrier  of  the  germs  of  diphtheria  or  typhoid  fever,  shall 
engage  in  the  production  or  handling  of  milk.  No  milk  produced 
in  a  dairy  in  which  such  a  person  comes  in  contact  with  the  milk 
shall  be  sold  or  offered  for  sale  until  it  has  been  pasteurized  under 
the  direction  of  the  health  officer. 

Regulation  — . — The  health  officer  shall  file  a  copy  of  the  per- 
mit of  each  milk  dealer,  and  of  the  score  card  of  each  dairy  in 
which  the  milk  is  produced,  with  the  clerk  of  the  board  of  health, 
and  the  records  shall  be  open  to  public  inspection. 

Regulation  — . — No  ice-cream  containing  milk  or  cream  which 
is  below  the  standard  of  purity  and  freshness  of  that  which  is 
sold  to  be  consumed  raw,  shall  be  sold  or  offered  for  sale. 

Regulation  — . — ^No  skimmed  milk  shall  be  sold  or  ofi'ered  for 


92  THE   HEALTH    OFFICER 

sale  unless  the  containers  are  plainly  labeled  "Skimmed  Milk," 
and  bear  the  date  on  which  it  was  drawn  from  the  cow. 

Regulation  — . — Each  bottle  or  other  container  in  which  milk 
is  dispensed  shall  be  labeled  with  the  date  on  which  the  milk 
was  drawn  from  the  cow. 

Regulation  — . — No  milk  shall  be  sold  or  offered  for  sale 
unless  it  shall  have  been  cooled  mimediately  after  milking  to  a 
temperature  below  60°  F..  and  kept  below  that  temperature  con- 
tinuously until  its  deli\'ery,  or  unless  it  shall  be  tlelivered  to  the 
consumers  within  two  hours  after  it  has  been  drawn  from  the 
cow. 

Regulation  — . — Except  with  the  permission  of  the  health 
officer,  no  stable,  water  closet,  garbage  heap,  or  manure  pile 
shall  be  maintained  within  100  feet  of  any  dairy  in  which  milk 
is  bottled,  pasteurized,  or  handled  for  sale. 

Regulation  — . — No  milk  shall  be  delivered  on  the  street  from 
open  cans  from  which  the  customer's  supply  is  dipped. 

Regulation  — . — No  milk  shall  be  sold  or  offered  for  sale 
which  falls  below  Grade  B. 

Food  Stores 

Regulation  — . — No  waiter,  cook,  clerk,  or  other  employee 
who  has  a  communicable  disease  or  is  a  carrier  of  disease  germs 
shall  be  allowed  to  work  in  a  restaurant,  hotel,  kitchen,  public 
dining-room,  grocery  store,  ice-cream  parlor,  soda-water  vending 
place,  bakery,  bakeshop,  candy  store,  candy  factory,  butcher 
shop,  dairy,  or  other  place  in  which  food  or  drink  is  prepared 
or  dispensed,  except  with  the  permission  of  the  health  officer, 
and  under  the  conditions  which  he  may  prescribe. 

Regulation  — . — No  food  or  drink,  including  ice-cream  and 
soda-water,  shall  be  prepared  or  dispensed  or  served  in  or  with 
dishes,  eating  utensils,  or  napkins  which  have  been  previously 
used  until  after  they  shall  have  been  cleansed  with  boiling  hot 
water. 

Regulation  — . — No  food  shall  be  prepared,  dispensed,  or 
served  in  any  public  eating  place  unless  the  kitchen  or  place  in 
which  the  food  is  kept,  prepared,  or  cooked  is  clean  in  every 
part,  including  the  cellar  and  ice-box,  and  unless  the  hands  and 
clothes  of  the  attendants  and  employees  are  clean. 

Regulation  — .- — No  food  shall  be  sold  or  offered  for  sale  in 
any  grocery,  butcher  shop,  or  fish  market,  or  other  food  shop  in 
which  any  marked  condition  of  uncleanness  or  filthiness  exists. 

Regulation  — . — No  food  or  drink  shall  be  sold  or  offered  for 
sale  that  has  been  left  uncovered  on  the  street  or  in  open  stalls, 
or  has  been  exposed  to  dust,  or  to  flies  or  other  vermin. 


LOCAL   SANITARY   CODE  93 

Regulation  — . — No  food  or  drink  shall  be  sold  or  offered  for 
sale  which  is  decayed,  or  is  contaminated  with  offensive  or 
poisonous  substances,  or  is  moldy  to  an  abnormal  degree,  or  is 
in  an  abnormal  state  of  fermentation.  The  health  officer  is 
hereby  authorized  to  condemn  any  article  which  is  unfit  for  food 
according  to  the  provisions  of  this  regulation. 

Regulation  — . — No  person  shall  slaughter  animals  in  the 

of except  in  places  and  under  the 

conditions  which  shall  be  prescribed  or  allowed  by  the  health 
officer  or  board  of  health.  No  meat  from  an  animal  that  has 
been  slaughtered  or  cut  up  in  a  slaughter  house  or  other  place 
that  is  in  an  unclean  or  filthy  state,  and  no  meat  that  has  been 
transported  under  unclean  or  filthy  conditions,  shall  be  sold  or 
offered  for  sale. 

Vermin 

Regulation  — . — No  person  shall  maintain  a  manure  pile, 
garbage  heap,  compost  heap,  or  any  other  collection  of  substances 
in  which  house-flies,  bluebottle-flies,  stable-flies,  or  other  flies 
which  are  detrimental  to  human  beings  or  domestic  animals  are 
breeding. 

Regulation  ■ — . — No  person  shall  maintain  a  cesspool,  rain- 
water barrel,  pail,  or  other  receptacle  for  water,  or  any  pool, 
marsh,  swamp,  or  other  collection  of  water,  in  such  a  condition 
that  mosquitoes  may  breed  in  it. 

Regulation  — . — No  person  afflicted  with  lice  in  any  form  shall 
be  allowed  to  be  present  at  any  school,  church,  or  other  public 
meeting  place,  or  to  visit  a  store  or  other  place  where  people 
commonly  assemble,  or  to  mingle  with  other  people.  No  clothes, 
hats,  or  other  wearing  apparel  containing  Hce  or  their  eggs  shall 
be  taken  from  the  premises  of  the  owner  or  other  person  respon- 
sible for  them  until  the  Hce  and  their  eggs  shall  have  been  killed 
by  heat  or  other  destructive  agent,  or  adequate  precautions  have 
been  taken  to  prevent  their  escape. 

Regulation  — . — No  collection  of  rubbish  shall  be  maintained 
in  such  a  state  that  it  is  a  breeding-place  for  rats  and  mice. 

Sewage 

Regulation  — . — No  waste  water,  household  slops,  or  other 
putrescible  liquids  shall  be  allowed  to  accumulate  upon  the  sur- 
face of  the  ground,  but  they  shall  be  emptied  upon  such  places, 
and  under  such  conditions,  that  they  quickly  seep  into  the 
ground. 

Regulation  — . — No  sewage  or  other  Kquid  containing  human 


94  THE  HEALTH   OFFICER 

excrement  shall  be  emptied  upon  the  surface  of  the  ground 
within  100  feet  of  a  dwelling. 

Regulation  — . — No  plumbing  fixtures  or  waste-pipes  for  the 
removal  of  waste  water  and  sewage  from  a  building  shall  be  con- 
structed in  such  a  manner  and  maintained  in  such  a  condition 
that  odors,  gases,  or  liquids  can  flow  backward  through  them, 
or  escape  through  their  walls  or  joints. 

Regulation  — . — Every  cesspool  shall  be  covered  in  such  a 
manner  that  flies  and  mosquitoes  cannot  enter  it.  No  cesspool 
or  other  device  for  the  disposal  of  sewage  shall  be  allowed  to 
overflow  upon  the  surface  of  the  ground  or  be  constructed  or 
maintained  within  50  feet  of  a  dwelling  or  private  source  of  water- 
supply,  or  in  a  location  from  which  its  drainage  will  render  the 
surrounding  soil  or  water  a  menace  to  health. 

Regulation  — . — Every  privy,  water-closet,  and  urinal  shall 
be  maintained  in  a  dry,  clean,  and  sanitary  state,  and  its  con- 
tents shall  be  protected  from  flies.  No  privy,  water-closet,  or 
urinal  shall  be  constructed  or  maintained  within  50  feet  of  a 
dwelling  or  source  of  water-supply. 

Regulation  — . — No  cesspool,  privy,  water-closet,  or  urinal 
shall  be  constructed  or  maintained  within  1000  feet  of  a  pubHc 
water-supply,  unless  it  or  its  receptacle  is  water-tight. 

Regulation  — . — No  person  shall  transport  sewage  or  the  clean- 
ings from  cesspools  or  privies  along  a  public  highway,  except  in 
closed,  water-tight  tanks,  and  unless  he  shall  have  a  written 
permit  from  the  health  officer,  and  shall  deposit  the  substances 
in  the  places  and  manner  which  the  health  officer  shah  require 
as  the  conditions  for  giving  the  permit. 

Regulation  — . — No  person  shall  deposit  sewage  or  cleanings 
from  cesspools  or  privies  upon  the  ground  within  1000  feet  of  a 
dwelling  or  source  of  water-supply.  (This  regulation  may  be 
desirable  under  exceptional  circumstances;  as,  for  example,  in 
order  to  force  the  installation  of  a  sewer  system  that  is  needed.) 

Regulation  — . — No  garbage  shall  be  allowed  to  lie  on  the 
surface  of  the  ground  more  than  twelve  hours.  The  receptacles 
for  garbage  shall  be  maintained  in  a  clean  and  odorless  state  at 
all  times,  and  their  contents  shall  be  protected  from  flies. 

Water 

Regulation  — . — No  person  or  corporation  shall  maintain  a 
well,  spring,  or  faucet  whose  water  contains  sewage,  or  the 
harmful  products  of  sewage,  or  colon  bacilli,  as  a  source  of  water- 
supply  for  drinking,  cooking,  or  culinary  purposes.  No  such 
water  shall  be  used  for  laundry  purposes  without  the  consent 


LOCAL   SANITARY   CODE  95 

of  the  health  officer,  and  under  the  conditions  which  he  shall 
impose. 

Regulation  — . — Water  containing  an  excessive  amount  of 
iron,  magnesium,  lime,  or  other  mineral  matter,  or  is  turbid  or 
discolored,  or  deposits  a  sediment  on  standing,  or  has  an  of- 
fensive odor  or  taste,  shall  be  considered  to  be  impure,  and  the 
board  of  health,  after  an  investigation,  may  issue  an  order  for- 
bidding its  use  for  drinking,  cooking,  culinary,  or  laundry  pur- 
poses except  with  the  consent  of  the  health  officer,  and  under 
the  conditions  which  he  shall  impose. 

Stream  Pollution 

Regulation  — . — No  person  shall  deposit  any  sewage,  water- 
closet  cleanings,  or  drainage  containing  human  excrement,  or 
any  dead  animals,  garbage,  kitchen  waste,  barnyard  drainage, 
animal  refuse,  or  other  substance  which  may  putrefy,  in  any 
stream,  lake,  estuary,  bay,  or  other  body  of  water,  or  allow  the 
same  to  enter  the  water  without  a  permit  from  the  board  of 
health,  and  unless  the  substance  shall  have  been  purified  to  such 
a  degree  that  it  does  not  contain  the  germs  of  human  diseases, 
and  will  not  undergo  further  putrefaction.  No  permit  shall  be 
granted  for  the  deposit  of  any  such  material  in  any  body  of 
water  until  a  written  application  shall  have  been  made  to 
the  board  of  health,  stating  the  character  and  amount  of  the 
material  and  the  manner  of  its  conveyance  to  the  water,  and 
until  the  board  shall  have  held  a  public  hearing  on  the  apph- 
cation. 

Manure 

Regulation  — . — No  person  shall  maintain  a  manure  pile, 
compost  heap,  or  other  collection  of  decaying  barnyard  material 
in  such  a  condition  that  it  is  a  breeding-place  for  flies,  or  gives 
off  offensive  odors  or  drainage.  Between  the  first  day  of  June 
and  the  first  day  of  October  of  each  year  every  collection  of 
stable  manure  shall  either  be  carted  away  at  least  once  a  week 
and  spread  upon  the  land,  or  be  securely  screened  from  flies,  or 
be  treated  with  substances  which  will  prevent  the  breeding  of 
flies  in  it.  (Some  villages  may  wish  to  enact  an  ordinance  re- 
quiring that  manure  shall  be  kept  in  covered  bins  constructed 
of  concrete.  Some  will  want  to  exclude  the  importation  of 
manure  during  the  summer  months.) 


96  the  health  officer 

Keeping  Animals 

Regulation  — . — No  pigs  shall  be  kept  within  100  feet  of  a 
dwelling  or  public  meeting  place,  or  within  the  area  bounded  by 
■ (This  regulation  is  in  accord- 
ance with  the  Village  Law  of  New  York  State,  Sec.  90,  Subdivi- 
sion 29.) 

Regulation  — . — No  pigpen,  stable,  barnyard,  or  house  or 
enclosure  for  fowl  shall  be  maintained  within  100  feet  of  a  dwell- 
ing or  public  meeting  place,  or  in  a  wet,  uncleanly  state,  or  in 
such  a  condition  that  flies  may  breed  in  it.  (This  regulation 
will  enable  the  board  of  health  to  eliminate  stables,  etc.,  from  a 
residential  district.) 

Offensive  Odors 

Regulation  — . — No  person  shall  deposit  or  maintain  any 
garbage,  refuse,  manure,  sewage,  or  other  substance  which  gives 
off  offensive  odors  upon  any  highway  or  public  place,  or  in  any 
place  from  which  the  odors  may  escape  and  become  offensive 
to  human  beings. 

Regulation  — . — No  person  shall  establish,  maintain,  or  con- 
duct a  business,  trade,  or  occupation  in  which  offensive  odors, 
or  excessive  dust  or  smoke  are  produced,  to  the  disturbance 
of  the  comfort  and  repose  of  a  considerable  number  of  persons. 

Housing 

Regulation  — . — No  house  that  is  in  such  a  dilapidated  condi- 
tion or  state  of  filthiness  or  uncleanness  as  to  endanger  the 
health  or  life  of  any  person  that  occupies  it,  or  that  is  not  fur- 
nished with  a  safe  water-supply  or  with  toilet  facilities,  shall  be 
used  as  a  dwelling,  or  rented  for  that  purpose.  The  board  of 
health  may  investigate  such  dwelling,  and  if  conditions  are 
found  to  be  dangerous  to  health  or  life,  it  may  order  the  health 
officer  to  post  a  notice  upon  the  house  declaring  the  building 
unfit  for  human  habitation,  and  may  institute  a  suit  to  dispossess 
the  occupants.  (There  may  be  a  question  regarding  the  legality 
of  this  regulation.  If  the  state  adopts  a  housing  law,  this  regu- 
lation may  be  unnecessary.) 

It  is  also  desirable  that  a  local  board  of  health  shall  enact 
ordinances  controlling  barber-shops,  and  the  use  of  common 
towels,  common  drinking-cups  and  eating  utensils,  and  forbidding 
spitting  in  public  places.  The  Sanitary  Code  of  New  York  State 
contains  model  regulations  on  these  subjects. 


CHAPTER  X 
VITAL  STATISTICS 

Value. — The  term  vital  statistics  means  numbers  relating  to 
population,  marriages,  births,  diseases,  and  deaths,  together  with 
a  discussion  of  the  conditions  which  affect  those  numbers.  A 
record  of  vital  statistics  is  one  of  the  severest  tests  of  a  health 
department.  It  is  the  means  by  which  progress  in  public  health 
may  be  traced  from  year  to  year  and  from  one  administration 
to  another.  It  enables  a  health  department  to  set  a  definite 
goal  of  attainment;  and  the  degree  of  approach  to  that  goal 
may  be  taken  as  a  measure  of  the  success  of  the  work  of  the  de- 
partment. The  goal  set  by  the  New  York  State  Department 
of  Health  in  1914  was  the  saving  of  25,000  lives  within  five  years. 
The  Connecticut  Department  of  Health  in  1917  guaranteed  to 
save  one  life  for  every  $500  of  its  appropriation.  These  ideals 
can  be  accom.phshed  only  by  a  careful  study  of  all  phases  of  the 
vital  statistics  of  the  past,  and  by  the  application  of  lessons  drawn 
from  them  to  future  methods  of  pubHc  health  work. 

A  group  of  figures  taken  alone  may  be  used  to  prove  the  most 
contradictory  statements.  Many  elements  enter  into  an  inter- 
pretation of  vital  statistics,  and  erroneous  conclusions  will  be 
drawn  unless  all  the  elements  are  considered.  The  death-rate 
among  college  students,  for  example,  is  extremely  low  in  com- 
parison with  the  death-rate  among  the  whole  population.  The 
comparison,  in  order  to  be  of  value,  must  be  made  not  with  the 
death-rate  among  old  men  and  babies,  but  with  that  among 
young  men  of  the  same  age  as  the  college  boys.  A  community 
that  boasts  of  the  universally  great  age  at  which  its  inhabitants 
die  may  be  one  from  which  the  young  and  active  boys  have 
moved  away,  leaving  only  the  older  folk.  The  system  of  vital 
statistics  used  by  the  states  and  larger  cities  is  not  complicated 
or  difficult  to  learn,  and  it  is  the  duty  of  every  health  officer  to 
understand  the  principles  on  which  the  system  is  founded. 

Population  is  the  basis  of  all  vital  statistics.  It  is  deter- 
mined by  a  national  census  taken  every  ten  years  at  the  begin- 
ning of  each  decade.  New  York  arid  other  states  also  take  a 
census  in  the  years  ending  with  5,  and  thus  a  census  is  available 
every  five  years.  The  census  includes  the  age,  sex,  nationality, 
occupation,   and  other  personal  data  of  each  inhabitant.     A 

7  97 


98  THE   HEALTH    OFFICER 

tabulation  of  the  facts  is  made  for  each  municipality,  and  a  re- 
port of  all  the  facts  relating  to  its  population  may  be  obtained 
from  the  United  States  Census  Bureau,  Washington,  D.  C. 

Population  is  not  an  absolutely  accurate  number,  but  is  an 
estimate.  ■  People  are  constantly  moving.  Some  die  and  others 
are  born  every  day.  The  Federal  Census  is  taken  as  the  popu- 
lation was  on  April  15th  of  the  census  year. 

The  population  of  a  locality  is  affected  by  the  season  of  the 
year  during  which  the  census  is  taken.  A  large  city  contains 
fewer  inhabitants  in  summer  than  in  winter.  The  New  York 
State  census  of  1915  was  taken  in  the  summer  while  thousands 
of  people  were  away  at  summer  resorts.  Its  figures  are  not 
accepted,  but  the  Department  of  Health  uses  an  estimated 
population  based  on  the  Federal  Census  of  1910. 

The  population  of  a  locahty  is  affected  by  the  presence  of 
large  institutions.  A  state  hospital  located  in  a  rural  district 
increases  the  population  and  the  death-rate  to  such  a  degree 
that  the  vital  statistics  of  that  municipality  have  no  value  un- 
less the  figures  for  both  population  and  deaths  for  the  institution 
are  excluded. 

Estimated  Population. — The  population  of  nearly  every  coun- 
try and  municipality  is  growing,  and  considerable  errors  will  be 
made  in  the  vital  statistics  unless  corrections  are  made  for  the 
growth  during  the  intercensal  periods.  The  corrections  are 
made  by  either  the  arithmetic  or  the  geometric  method.  The 
basis  of  both  methods  is  the  growth  during  the  preceding  inter- 
censal years. 

The  arithmetic  method  is  performed  according  to  the  meth- 
ods of  arithmetic  progression,  and  is  as  follows: 

1.  Find  the  average  yearly  increase  in  population  during  the 
last  intercensal  period. 

2.  Multiply  it  by  the  years  elapsing  since  the  last  census. 

3.  Add  the  product  to  the  population  according  to  the  last 
census. 

Example. — The  population  of  a  city  on  January  1,  1900,  was 
15,000,  and  January  1,  1910,  20,000.  What  was  its  estimated 
population  on  January  1,  1912? 

The  growth  from  1900  to  1910  was  5000,  or  an  average  annual 
increase  of  500.  The  increase  in  the  two  years  from  1910  to 
1912  will  be  1000,  which,  added  to  20,000,  gives  21,000  as  the 
estimated  population  for  1912. 

The  estimation  of  the  population  for  any  intercensal  year 
would  be  made  in  the  same  manner  as  that  for  a  post-censal 
year.  For  example,  the  population  in  1917  would  be  500  X  7  -|- 
15,000  =  18,500. 


VITAL   STATISTICS  99 

When  exactness  is  required,  the  increase  is  estimated  for 
fractions  of  a  year.  The  estimated  midyear  population,  or  that 
on  July  1st,  is  used  as  the  population  for  the  entire  year.  The 
Federal  Census  is  taken  as  of  April  1st.  The  midyear  popula- 
tion would,  therefore,  be  the  population  on  April  1st,  increased 
by  T%  of  the  average  annual  increase.  Thus,  the  population  on 
July  1,  1900,  would  be  A  X  500  +  15,000  =  15,125. 

The  geometric  method  of  estimating  population  is  based  on 
a  fixed  yearly  rate  of  increase,  and  is  similar  to  the  method  of 
computing  the  amount  in  compound  interest.  If  A  represents 
the  amount,  P,  the  principal,  R,  the  rate  per  cent.,  and  N,  the 
number  of  years,  the  formula  for  calculating  the  amount  at  the 
end  of 

1  year  is     A  =  P  (l  +  R) 

2  years  is  A  =  P  (1  +  Rf 

3  years  is  A  =  P  (l  +  Py 
N  years  is  A  =  P  {I  +  R)'' 

When  these  formulas  are  applied  to  vital  statistics,  A  corre- 
sponds to  the  required  population;  P,  to  the  population  given 
by  the  census;  R,  to  the  annual  rate  per  cent,  of  increase;  and 
N,  to  the  years  elapsed  since  the  census.  The  formula  for  the 
population  at  the  end  of 

(1)  1  year  is     A  =  P  {1  +  R) 

(2)  2  years  is    A  =  P  (i  +  R)' 

(3)  3  years  is    A  =  P  (l  +  R)' 

(4)  N  years  is  ^  =  P  (1  +  i?)"" 

(5)  10  years  is  ^  =  P  (1  +  Ry° 

When  the  rate  of  increase  is  known,  the  calculation  for  the 
population  may  easily  be  made  by  the  simple  methods  of  arith- 
metic; but  when  the  rate  is  not  known,  it  must  be  found  by  the 
use  of  logarithms.     Taking  the  last  formula,  we  have 

(6)  ^  =  P  (1  +  i?)^" 

(7)  log.  A  =  log.  P  -^  10  log.  (1  +  R) 

(8)  10  log.  (1  +  R)  =  log.  A  —  log.  P 


(9)       log.  (1  +  P)  = 


log.  A  —  log.  P 

16 


Let  us  apply  the  formula  to  the  following  problem:  The 
population  of  a  city  on  January  1,  1900,  was  15,000,  and  on 
January  1,  1910,  20,000.  What  was  the  rate  per  cent,  of  its 
annual  increase?  What  would  be  the  population  on  January  1, 
1912,  calculated  by  the  geometric  method? 


A  =  20,000 
P  _=  15,000 
R  is  unknown 


100  THE  HEALTH   OFFICER 

By  substituting,  formula  (9)  becomes: 

(io)iog.(i  +  i?)  =  ^"^-^»'^"-'"g-^^'QQQ 

(11)  log.  20,000      =4.301030 

(12)  log.  15,000      =  4.176091 

(13)  difference  =  0.124939 

(14)  ,V  difference  =  0.012494  =  log.  (l  +  R) 

0.012494  is  the  logaritkm  of  1.0292;  and  0.0292  is,  therefore, 
the  annual  rate  of  increase  of  population. 

The  population  on  January  1,  1912,  would  be  20,000,  mul- 
tiplied by"  1.029  squared.  The  square  of  1.0292  is  1.0592; 
1.0592  X  20,000  =  21,184  =  population  on  January  1,  1912. 

If  the  problem  were.  What  would  the  population  be  on  July  1, 
1912,  it  could  not  be  solved  by  aritlimetic,  for  there  is  no  way 
of  raising  1.029  to  the  2|  power  by  arithmetic  methods.  Loga- 
rithms must,  therefore,  be  used. 

Taking  formula  (4).     A  =  P  {1  +  R)'' 
N  =  2.5  years 
P  =  20,000 
R  =  0.0292 

Applying  logarithms,  we  have 

(15)  log.  A   =  log.  20,000  +  2.5  log.  1.0292 
log.  1.0292  =  0.012494 

(16)  2.5  log.  1.0292  =  0.031235 

(17)  log.  20,000  =  4.301030 

(18)  log.  A  =  4.332265  =  log.  21,492 

(19)  A  =   21,492  =  population  on  July  1,  1912 

If  the  population  on  July  1,  1912,  were  calculated  by  the 
arithmetic  method,  the  result  would  be 

2.5  X  500  +  20,000  =  21,250 

The  two  methods,  therefore,  do  not  give  the  same  results. 
The  correctness  of  the  results  is  tested  by  their  agreement  with 
the  figures  of  the  next  census.  The  experience  of  New  York 
City  is  that  the  population  calculated  by  the  arithmetic  method 
agrees  with  the  census  more  closely  than  that  calculated  by  the 
geometric  method.  The  geometric  method  is  the  more  reliable 
when  the  rate  of  growth  is  uniform  over  a  series  of  years.  When 
the  rate  of  growth  is  irregular,  the  arithmetic  method  is  the  more 
exact.  The  United  States  Bureau  of  Census  uses  the  arithmetic 
method. 

Registration  Area. — The  rates  of  marriages,  births,  and  deaths 
are  based  on  the  compulsory  registration  of  the  events.     The 


VITAL   STATISTICS  101 

registration  is  incomplete  in  many  parts  of  the  United  States. 
Those  states  in  which  death  certificates  are  required  before 
burial  form  what  is  called  the  regisiration  area  which  is  recog- 
nized by  the  United  States  Census  Bureau.  The  registration 
area  now  comprises  the  following  states:  California,  Colorado, 
Connecticut,  Indiana,  Kentucky,  Maine,  Maryland,  Massachu- 
setts, Michigan,  Minnesota,  Missouri,  Montana,  New  Hamp- 
shire, New  Jersey,  New  York,  North  Carolina,  Ohio,  Pennsyl- 
vania, Rhode  Island,  Utah,  Vermont,  Virginia,  Washington,  and 
Wisconsin,  together  with  the  District  of  Columbia. 

Marriages. — The  marriage  rate  is  expressed  by  three  methods: 

1.  The  number  of  persons  married  annually  in  each  1000  of 
population. 

2.  The  number  of  marriages  annually  in  each  1000  of  popu- 
lation. This  figure  will  be  exactly  one-half  of  that  derived  by 
method  No.  1. 

3.  The  number  of  marriages  annually  in  each  1000  unmar- 
ried, widowed,  and  divorced  persons  over  15  years  of  age. 

Some  of  the  more  important  influences  which  affect  the  mar- 
riage rate  are : 

1.  The  age  at  marriage  is  increasing,  with  a  corresponding 
decrease  in  the  marriage  rate.  In  Massachusetts  the  average 
age  at  marriage  is  now  twenty-nine  years  among  men  and 
twenty-five  years  among  women. 

2.  The  employment  of  women  tends  to  reduce  the  marriage 
rate  by  making  them  self-supporting. 

3.  Good  times  and  prosperity  promote  marriages. 

4.  The  marriage  rate  in  cities  is  greater  than  in  country 
districts.  One  reason  is  that  the  proportion  of  persons  of 
marriageable  age  in  cities  is  greater  than  in  rural  districts. 

Marriages  themselves  do  not  directly  constitute  a  public 
health  problem,  and  a  health  officer  has  little  or  nothing  to  do 
with  them.  Licenses  in  New  York  State  are  issued  by  clerks 
of  towns  and  cities,  and  after  marriage  they  are  returned  to  the 
clerk  that  issued  them,  and  are  filed  by  him  with  the  county 
clerk,  who  finally  files  them  with  the  State  Department  of 
Health. 

Registration  of  Births. — The  number  of  births  in  a  com- 
munity is  ascertained  by  means  of  the  compulsory  registration 
of  every  child  that  is  born.  The  public  health  law  of  New  York 
State,  Section  382,  requires  that  every  physician  and  midwife 
shall  register  a  birth  within  five  days.  The  reports  of  births 
everywhere  in  the  United  States  have  been  incomplete  in  the 
past;  but  the  frequent  necessity  of  producing  a  birth  certificate 
for  legal  uses  is  having  its  effect  in  the  requirements  for  a  com- 


102  THE   HEALTH    OFFICER 

piete  registration.  New  York  City,  after  a  campaign  of  prose- 
cutions against  delinquent  physicians  and  midwives,  has  suc- 
jceeded  in  getting  over  98.5  per  cent,  of  births  registered. 
\J  Value  of  Birth  Certificates. — Birth  certificates  are  necessary 
in  order  that  sanitarians  and  the  government  may  have  a  com- 
plete record  of  vital  statistics.  They  are  also  used  as  the  basis 
for  calculating  infant  mortahty  rates,  and  for  testing  the  results 
of  child  h}-giene  work. 

Birth  certificates  often  have  a  great  value  to  those  persons 
whose  births  are  registered.  The  following  are  some  of  the 
personal  uses  to  which  birth  records  are  put : 

1.  Evidence  of  age  on  entering  school. 

2.  Inheritance  of  property,  proof  of  age  and  relationship. 

3.  Proving  age  of  consent  in  court. 

4.  Marriage  licenses.  A  birth  certificate  is  required  in  some 
European  countries. 

5.  Passports.  A  birth  certificate  is  required  by  the  United 
States  Government. 

6.  Obtaining  working  papers.  In  many  states  a  child  be- 
tween fourteen  and  sixteen  years  of  age  cannot  obtain  employ- 
ment without  evidence  of  age. 

7.  Entrance  into  the  miHtary  or  naval  seryice  of  the  United 
States. 

Form  of  Certificate. — The  birth  certificate  that  is  used  in 
New  York  and  most  other  states  is  that  known  as  the  United 
States  Standard  Certificate  which  was  designed  by  a  com- 
mittee of  the  American  Public  Health  Association.  It  contains 
twenty-one  items  of  information  regarding  the  personal  and 
family  history  of  the  child.  It  is  a  permanent  record  which  is 
preserved  in  the  office  of  the  Department  of  Health. 

Securing  Complete  Registrations. — Birth  registration  laws 
require  physicians  and  midwives  to  report  births,  but  in  order 
to  compel  them  to  obey  the  laws  the  unrecorded  children  must 
be  found.  Some  of  the  means  of  discovering  the  unrecorded 
births  are: 

1.  A  comparison  of  the  death  record  of  every  child  under 
one  year  of  age  with  the  birth  register. 

2.  Obtaining  names  and  ages  of  babies  by  inspectors  and 
visiting  nurses,  and  comparing  them  with  the  birth  register. 

3.  Advertisements  of  births  in  newspapers,  or  news  items  re- 
garding births. 

4.  The  applications  for  birth  certificates. 

Birth-rate. — The  crude  birth-rate  is  the  number  of  births 
annually  in  each  1000  inhabitants  regardless  of  sex  or  age. 
The  crude  rate  does  not  afford  a  uniform  basis  for  comparing 


VITAL   STATISTICS  103 

the  birth-rates  of  two  localities,  for  the  one  in  which  there  is  an 
excess  of  males  would  have  the  lower  rate. 

One  form  of  refined  birth-rate  is  the  number  of  births  an- 
nually in  each  1000  women  between  the  ages  of  fifteen  and 
forty-five  years.  This  rate  does  not  express  the  true  condition 
when  a  city  containing  a  large  number  of  unmarried  women 
servants  is  compared  with  one  composed  of  families  of  laborers. 

A  second  form  of  refined  birth-rate  is  the  number  of  births 
annually  in  each  1000  married  women  between  the  ages  of  fifteen 
and  forty-five  years.  This  rate  is  the  best  basis  of  comparison 
between  cities  differing  widely  in  the  class  of  their  inhabitants. 

Most  birth-rates  that  are  published  are  the  crude  rates. 
What  a  health  ofi&cer  wants  to  know  principally  is  who  are  born 
and  where  the  children  live. 

A  weekly  birth-rate  is  the  rate  which  would  be  obtained  for 
a  year  if  the  number  of  births  during  each  week  of  the  year 
were  the  same  as  the  number  during  the  given  week  for  which 
the  rate  is  computed.  For  example,  during  the  second  week  in 
June  there  were  10  births  in  a  city  of  25,000  inhabitants.  What 
is  the  weekly  birth-rate? 

The  number  of  births  in  a  year,  if  10  occurred  each  week, 
could  be  10  X  52.17747  =  522.  This  divided  by  25  (the  num- 
ber of  thousands  of  inhabitants)  gives  20.88  as  the  birth-rate  for 
that  week. 

A  monthly  rate  would  be  calculated  in  the  same  manner. 
If  extreme  accuracy  is  necessary,  the  health  ofHcer  would  use 
the  exact  number  of  days  in  the  particular  month  for  which  he 
was  calculating  the  rate,  and  the  exact  number  of  days  in  a 
year  (365.24226). 

The  birth-rates  in  different  countries  show  a  wide  variation. 
The  rate  in  Hungary  (36  in  1912)  was  the  highest  among  people 
who  keep  accurate  records,  while  that  in  France  (19)  was  the 
lowest.  The  birth-rate  in  New  York  State  in  1916  was  23.3. 
The  birth-rate  in  nearly  all  countries  is  falling. 

Some  of  the  important  factors  which  influence  the  birth-rate 
are: 

1.  Increase  in  the  age  at  which  marriage  is  contracted. 

2.  Decrease  in  the  number  of  marriages. 

3.  Ease  of  obtaining  divorces. 

4.  Economic  conditions.  Prosperity  increases  the  number 
both  of  marriages  and  of  births. 

5.  Avoidance  of  child  bearing  by  women  at  child-bearing  ages. 
There  is  much  discussion  about  the  decKne  in  the  birth-rate. 

A  condition  that  is  as  important  as  the  number  of  births  is  the 
quality  of  the  children  that  are  born  and  reared. 


104  THE   HEALTH    OFFICER 

Death  Certificates.— Certiikates  of  death  are  required  be- 
fore burial  by  most  states.  Since  practically  all  deaths  are 
known,  the  certificates  form  a  reliable  basis  for  the  enumeration 
of  deaths.  The  certificates  used  by  New  York  and  other  states 
is  that  known  as  the  United  States  Standard  Certificate  of  death. 
It  has  twenty  items  to  be  filled  out  by  the  physician,  health 
officer,  or  coroner,  and  these  items  form  the  basis  on  which 
death  statistics  are  compiled.  The  certificates  are  preserved  in 
the  office  of  the  Department  of  Health. 

y Cause  of  Death. — Accuracy  in  diagnosis  and  uniformity  inr 
terms  are  necessary  in  obtaining  reliable  statistics  concerning 
the  causes  of  death.  The  international  list  of  causes  of  death  is 
the  authoritative  standard  by  which  a  physician  can  determine- 
the  proper  temis  to  use  in  making  out  a  death  certificate.  The 
Hst  is  published  by  the  Bureau  of  the  Census,  Washington,  D.  C, 
and  will  be  sent  to  any  physician  applying  for  it. 

A  certificate  has  two  blank  spaces  for  the  causes  of  death, 
one  for  the  primary  cause  and  one  for  the  contributory  or  sec- 
ondary cause.  Physicians  are  sometimes  uncertain  whether  a 
condition  is  to  be  considered  a  primary  or  a  secondary  cause. 
A  cause  is  to  be  considered  primary  when  it 

1.  Is  the  first  to  develop  or  is  of  the  longer  duration.  Ex- 
ample, measles,  primary;  bronchopneumonia,  secondary. 

2.  Is  a  disease  of  which  the  other  is  a  recognized  complica- 
tion. Example,  scarlet  fever,  primary;  acute  nephritis,  sec- 
ondary. 

3.  Is  a  general  disease  affecting  the  whole  system  in  distinc- 
tion to  a  local  affection.  Example,  diabetes,  primary;  gangrene 
of  foot,  secondary. 

4.  Is  the  more  acute  and  dangerous  of  two  coexisting  condi- 
tions. Example,  gastric  ulcer,  primary;  tuberculosis  of  lungs, 
secondary. 

Sudden  deaths  frequently  occur  for  which  no  sufficient  cause 
is  found.  Physicians  usually  ascribe  the  cause  either  to  some 
form  of  heart  trouble  or  to  apoplexy,  but  this  is  unsatisfactory 
unless  there  is  clear  evidence  of  disease  of  the  heart  or  brain. 
Acute  dilatation  of  the  heart  is  a  favorite  diagnosis,  but  this  is 
merely  a  terminal  symptom  and  does  not  explain  the  under- 
lying cause.  The  proper  statement  to  make  on  the  death 
certificate  is,  "Sudden  death.  No  cause  found  on  investiga- 
tion." 

Insane  persons  often  die  as  the  result  of  insanity  alone. 
The  proper  form  of  certificate  is  chronic  mental  disease  for  the 
primary  cause  of  death,  and  general  weakness  for  the  contribu- 
tory cause.     If  pneumonia  or  nephritis  or  other  condition  was 


VITAL   STATISTICS  105 

the  immediate  cause  of  death,  it  is  to  be  entered  as  the  c(jn- 
tributory  cause. 

Many  different  names  are  often  applied  to  the  same  condi- 
tion. A  fever  of  which  the  typhoid  bacillus  is  the  cause  has 
over  twenty  different  names,  and  tuberculosis  has  over  a  dozen, 
every  one  of  which  is  often  used  to  conceal  the  true  condition. 
When  a  specific  germ  is  the  cause  of  sickness,  the  disease  takes 
its  name  from  the  germ  and  the  part  affected.  If  the  disease  is 
typhoid,  call  it  typhoid,  and  if  it  is  tuberculosis,  call  it  that. 

Much  is  written  about  inaccuracies  of  diagnosis,  and  it  is 
alleged  that  wrong  causes  are  assigned  to  over  half  of  the  cases 
that  are  investigated  on  autopsy.  The  value  of  vital  statistics 
in  public  health  work  does  not  depend  upon  an  accurate  patho- 
logic diagnosis  so  much  as  upon  a  clear  statement  of  the  general 
condition  of  the  patient.  Ill-defined  conditions  resulting  in 
death  are  often  due  to  malnutrition,  fatty  degeneration,  arterio- 
sclerosis, or  sudden  high  blood-pressure  following  dietary  in- 
discretions; and  yet  sometimes  no  definite  cause  of  death  can 
be  named  when  these  conditions  prove  fatal.  The  rule  in  these 
conditions  is  to  state  the  cause  of  death  as  accurately  as  pos- 
sible in  an  explanatory  sentence,  and  not  try  to  name  a  particular 
disease. 

Death-rate. — The  crude  death-rate  is  the  number  of  deaths 
occurring  annually  in  each  1000  of  population.  It  is  found  by 
dividing  the  number  of  deaths  in  a  year  by  the  population  in 
thousands.  For  example,  310  deaths  occurred  during  1916  in 
a  city  having  15,500  inhabitants.  The  death-rate  is  310  -^  15.5 
=  20.  A  quarterly,  or  monthly,  or  weekly  death-rate  is  cal- 
culated in  the  same  manner  as  the  corresponding  birth-rate 
(p.  193).  The  death-rate  for  the  whole  year  is  based  on  the 
estimated  midyear  population.  When  the  expression  "death- 
rate"  is  used  alone,  without  a  qualifying  adjective,  the  crude 
rate  is  meant. 

The  death-rate  of  a  community  is  influenced  by  a  number 
of  factors,  among  which  sanitation  and  the  prevalence  of  diseases 
are  the  most  important.  Improvements  in  sanitary  conditions 
and  the  application  of  measures  for  the  protection  of  health  have 
reduced  the  death-rate  in  New  York  City  from  26  to  less  than  14 
within  twenty-five  years.  The  crude  death-rate  is  often  taken 
as  the  standard  by  which  the  healthfulness  of  a  place  may  be 
judged,  but  it  is  not  a  true  index  unless  all  other  factors  which 
influence  the  death-rate  are  excluded.  A  death-rate  in  which 
allowance  is  made  for  other  factors  besides  diseases  and  sanita- 
tion is  called  a  corrected  death-rate. 

Correction  for  Institutions. — A  factor  which  may  have  a 


106  THE   HEALTH    OFFICER 

great  influence  on  the  death-rate  of  a  conmiunity  is  the  pres- 
ence of  a  large  home,  ahnshouse,  hospital,  or  other  institution. 
A  state  hospital  for  the  insane  may  have  2000  inmates  with  100 
deaths  annually.  The  corrected  death-rate  would  be  calculated 
upon  the  deaths  remaining  after  those  of  non-resident  inmates 
had  been  deducted;  and  the  population  would  be  that  of  the 
town  after  the  number  of  non-resident  inmates  had  been  de- 
ducted. For  example,  a  town  has  20,000  population  within  its 
borders,  2000  of  whom  are  inmates  of  a  state  hospital  and  come 
from  outside  the  town.  The  total  number  of  deaths  within 
the  boundaries  of  the  town  during  1916  was  350,  of  which  100 
occurred  among  the  inmates.  The  crude  death-rate  was  350  -r- 
20  =  17.5.  The  corrected  death-rate  based  on  250  deaths 
among  18,000  population  was  250  -^  18  =  13.9.  It  would  be 
unfair  and  misleading  to  judge  the  sanitation  and  prevalence 
of  diseases  in  a  town  by  the  crude  death-rate.  The  rule  in  cal- 
culating death-rates  is  to  exclude  non-residents  from  both  the 
population  and  the  deaths,  and  to  charge  the  deaths  of  non- 
residents to  the  municipality  in  which  those  dying  had  their 
residence. 

Correction  for  Age. — An  allowance  for  the  age  distribution  of 
population,  and  for  deaths  among  various  age  groups,  must  be 
made  in  interpreting  the  death-rate  of  a  community,  or  in  com- 
paring the  rate  of  one  municipahty  with  that  of  another.  The 
following  table  shows  the  approximate  percentage  of  population 
in  various  age  groups  of  New  York  City  in  1913,  and  their  death- 
rates:  „      ,      , 

Percentage  of 
lAges.  population.        Death-rate. 

Under  5  years 11.5  40.0 

5-14  years 19.0  3.3 

15-24  years 19.1  4.0 

25-44  years 34.0  9.0 

45-64  years 13.6  28.0 

65  years  and  over 2.8  96.0 

All  ages 100.0  13.76 

The  death-rates  among  the  different  age  groups  in  the  table 
range  from  less  than  4  to  nearly  100.  The  percentage  of  per- 
sons at  different  ages  varies  in  the  various  municipalities.  If  a 
municipality  contains  an  excess  of  young  persons,  it  will  have  a 
low  death-rate.  An  excess  of  the  number  of  babies,  or  of  old 
people,  will  increase  the  death-rate.  Japan  has  a  large  birth- 
rate, and  the  great  number  of  young  children  produces  a  high 
crude  death-rate.  The  population  of  the  newer  Western  States 
consists  largely  of  young,  vigorous  persons,  among  whom  the 
death-rate  is  naturally  small.  The  differences  among  cities, 
states,  and  countries  are  so  great  that  the  effect  of  the  age  group- 


VITAL   STATISTICS  107 

ing  of  the  population  must  be  considered  in  comparing  their 
death-rates. 

The  reports  of  boards  of  health  of  the  states  and  larger  cities 
often  give  both  the  crude  death-rates  and  the  corrected  rates. 
The  corrections  are  usually  those  which  are  made  for  age  group- 
ings. There  are  several  methods  of  calculating  a  corrected 
death-rate.  The  one  in  common  use  is  that  which  is  recom- 
mended by  the  International  Statistical  Institute  and  is  based 
on  the  age  grouping  of  the  population  of  Sweden,  and  which  is 
as  follows: 

Percentage  of  Number  per 

Age.  population.        1,000,000  people. 

Under  1  year 2.65  26,500 

1-19  years 39.81  398,100 

20-50  years 38.62  386,200 

50  years  and  over 18.92  189,200 

Total 100.00  1,000,000 

The  corrected  death-rate  which  is  based  on  the  population  of 
Sweden  is  called  a  standardized  death-rate.  The  method  of 
computing  the  standardized  or  corrected  death-rate  of  a  city  is 
as  follows: 

1.  Calculate  the  death-rate  of  each  age  group  of  the  city. 

2.  Take  the  corresponding  age  groups  of  the  population  of 
Sweden,  apply  the  death-rates  of  the  city  groups  to  them,  and 
calculate  the  number  of  deaths  that  would  occur  in  each  group. 

3.  Add  the  number  of  theoretic  deaths  in  the  groups.  This 
will  give  the  number  of  deaths  that  would  occur  in  Sweden  if 
the  death-rates  of  the  Swedish  age  groups  were  the  same  as  those 
of  the  city. 

4.  Calculate  the  theoretic  death-rate  based  on  the  number  of 
theoretic  deaths.  This  will  be  the  corrected  death-rate  of  the 
city. 

The  following  example  will  illustrate  the  method  of  calculat- 
ing a  corrected  or  standardized  death-rate.  A  city  of  1,000,000 
inhabitants  has  a  crude  death-rate  of  15.  The  death-rates  of 
its  various  age  groups  are  as  follows: 

Under  1  year 100 

1-19  years 11 

20-50  years 6 

50  years  and  over 40 

What  will  be  the  corrected  death-rate? 

Solution. — The  number  of  persons  under  one  year  in  the 
standard  population  of  Sweden  is  26,500.  If  the  death-rate 
among  these  persons  were  the  same  as  that  in  the  city,  the 
number  of  deaths  would  be  26.5  X  100  =  2650. 

There  are  398,100  persons  between  one  and  nineteen  years  of 


108 


THE   HEALTH    OFFICER 


age  in  the  standard  population  of  Sweden.     If  the  death-rate 
were  11  the  number  of  deaths  would  be  398.1  X  11  =  4379. 

The  following  table  shows  the  number  of  theoretic  deaths 
for  all  the. age  groups: 

Number  of  thco- 
Swedish  Death-rates         retic  deaths  in 

Ages.  population.         of  the  city.  Sweden. 

Under  1  year 26,500  100  2,650 

1-19  years 398,100  11  4,379 

20-50  years 386,200  6  2,317 

50  years  and  over 189.200  40  7,568 

Total 1,000,000  ....  16,914 

The  total  number  of  theoretic  deaths  is  found  to  be  16,914 
in  a  population  of  1,000,000.  The  theoretic  death-rate  is,  there- 
fore, 16.9.  This  is  the  corrected,  or  standardized,  death-rate 
of  the  city,  and  is  considerably  higher  than  the  crude  rate.  The 
explanation  is  that  the  ages  of  the  people  in  the  city  are  favorable 
for  a  low  crude  death-rate. 

When  the  death-rate  of  the  various  cities  and  states  are 
standardized  and  corrected  according  to  a  common  method,  the 
effect  of  the  age  grouping  is  eliminated,  and  the  differences  in 
the  death-rates  are  then  due  almost  solely  to  sanitation  and 
health  protection  measures. 

Direct  Comparison  of  Death-rates. — The  death-rates  of  two 
cities  may  be  compared  directly  by  applying  the  death-rates  of 
the  age  groups  of  City  No.  1  to  the  numbers  of  people  in  the 
age  groups  of  City  No.  2.  Suppose,  for  example,  that  we  wish 
to  compare  the  death-rate  of  New  York  City  for  1913  with  that 
of  City  B  having  a  population  of  100,000,  a  crude  death-rate 
of  12.25,  and  an  age  distribution  and  age  death-rate  as  shown 
in  the  following  table.  The  table  also  shows  the  age  distribution 
in  City  B,  the  crude  death-rates  for  the  various  ages,  and  the 
results  obtained  by  applying  the  New  York  City  death-rates  to 
the  age  groups  of  City  B. 


Population  of  City  B. 

Actual 

number  of 

deaths 

in  B. 

Death- 
rate  of 
City  B. 

New  York 
City  death- 
rate. 

Theoretic  num- 
ber of  deaths 

Age  groups. 

Per- 
centage. 

Number. 

m      City     B 
based   on   the 
New        York 
death-rate. 

Under  5  years 
5-14  years.  . 
15-24  years.  . 
25-44  years .  . 
45-64  years .  . 
65  and  over .  . 
All  ages 

8.0 

20.0 

24.0 

38.5 

8.0 

1.5 

100.0 

8,000 

20,000 

24,000 

38,500 

8,000 

1,500 

100,000 

360 
80 
120 
385 
160 
120 
1225 

45.0 
4.0 
5.0 
10.0 
20.0 
80.0 
12.25 

40.0 

3.3 

4.0 

9.0 

28.0 

96.0 

320 

66 

96 

347 

224 

144 

1197 

Theoretic  death-rate  =  11.97. 


VITAL   STATISTICS  109 

The  crude  death-rate  of  New  York  City  for  1913  was  13.76, 
while  that  of  City  B  was  12.25.  A  comparison  of  the  crude 
rates  would  indicate  that  City  B  was  more  healthful  than  New 
York,  but  if  the  death-rates  of  New  York's  age  groups  hekl  good 
in  City  B,  the  death-rate  of  City  B  would  have  been  only  1 1.97. 

Infant  Mortality. — The  death-rate  among  children  under  one 
year  of  age  is  called  the  infant  mortality  rate.  It  is  the  number 
of  children  dying  among  every  1000  children  under  one  year  of 
age.  The  population  under  one  year  is  considered  to  be  the 
number  of  births  during  the  year.  This  figure  is  more  accurate 
than  the  number  obtained  by  the  census  enumerators.  Infant 
mortality  is,  therefore,  the  number  of  children  under  one  year 
old  dying  in  each  1000  births.  It  has  fallen  more  than  the 
death-rate  in  any  other  age  group.  It  was  288  in  New  York  City 
in  1890,  and  99  in  1914.  The  fall  has  been  due  largely  to  the 
edueation  of  mothers,  but  also  to  improved  milk-supplies,  and 
to  special  work  for  the  benefit  of  babies. 

There  is  a  marked  age  grouping  in  infant  mortality — 42  per 
cent,  of  the  deaths  are  among  children  under  one  month  old, 
and  are  due  to  congenital  causes  which  affect  the  mothers  be- 
fore the  children  are  born.  The  following  table  shows  the  per- 
centage of  deaths  among  infants  at  various  ages : 

Age.  Percentage  of  deaths. 

Under  1  month 42 

1  month 10 

2  months 8 

3,  4,  and  5  months 17 

6,  7,  and  8  months 13 

9,  10,  and  11  months 10 

Total 100 

Infants  form  a  special  age  group  which  is  recognized  by  the 
assignment  to  it  of  a  specialty  in  medicine,  pediatrics,  and  of  a 
special  division,  child  hygiene,  in  the  departments  of  health  of 
the  states  and  larger  cities. 

Special  Death-rates. — Death-rates  are  often  calculated  for 
individual  diseases.  They  are  usually  based  on  a  unit  of  100,000 
of  population  in  order  to  avoid  decimals,  or  fractions  of  a  death. 
The  death-rates  per  100,000  of  population  for  the  leading  dis- 
eases in  New  York  State  during  1916  were  as  follows: 

Pneumonia,  all  forms 167.1 

Tuberculosis,  all  forms 152.6 

Cancer 90.1 

Diarrheal  diseases  of  infants 51.2 

Poliomyelitis 32.0 

Diphtheria 14.7 

Measles 8.9 

Whooping-cough 7.2 

Typhoid  fever 5.8 


110  THE   HEALTH   OFFICER 

Morbidity  Rates. — The  statistics  which  have  the  most  v^alue 
to  a  health  officer  are  those  relating  to  the  number  of  cases  of 
communicable  diseases  in  his  jurisdiction.  IMost  states  require 
physicians  to  report  cases  of  contagious  diseases  to  the  depart- 
ment of  health,  but  the  list  of  diseases  and  the  manner  of  report- 
ing vary  widely.  The  New  York  law  requires  the  reports  to 
be  made  in  waiting  to  the  health  officer  immediately  after  the 
discovery  of  a  case,  and  by  the  health  officer  to  the  state  depart- 
ment of  health.     The  reportable  diseases  in  New  York  State  are: 

Anthrax. 

Chancroid. 

Chickenpox. 
~~\  Cholera,  Asiatic. 
\    Diphtheria  (membranous  croup). 
^    Dysentery,  amebic  and  bacillary. 
X    Epidemic  cerebrospinal  meningitis. 

Epidemic  or  streptococcus  (septic)  sore  throat. 

German  measles. 

Glanders. 

Gonorrhea. 

Measles. 

ISIumps. 
^      Ophthalmia  neonatorum. 
^ —  Paratyphoid  fever. 
]     Plague. 
K      Pneumonia. 

?      PoliomyeUtis,  acute  anterior  (infantile  paralysis). 
\     Puerperal  septicemia. 
;  Y  Rabies. 
I      Scarlet  fever. 
j       Smallpox. 

Syphilis. 

Trachoma. 

Tuberculosis. 

T^-phoid  fever. 
J     Typhus  fever. 

Whooping-cough. 

It  is  the  duty  of  every  health  officer  in  New  York  State  to 
keep  a  Hst  of  the  cases  of  the  reportable  diseases  in  his  district. 
The  records  are  not  complete,  for  many  existing  cases  are  diag- 
nosed as  diseases  which  are  not  communicable,  and  many  mild 
cases  are  not  reported  at  all.  It  is  extremely  desirable  that 
every  health  officer  shall  have  complete  statistics  regarding  all 
cases  of  communicable  diseases  in  his  district  in  order  that  he 
may  compare  each  year's  work  with  that  of  other  years,  and 


VITAL   STATISTICS  111 

may  demonstrate   the  value   and  efficiency  of  his  preventive 
work. 

The  number  of  cases  of  communicable  diseases  in  a  com- 
munity is  usually  expressed  by  the  number  per  100,000  of  popu- 
lation. Grave  errors  may  arise  from  calculating  disease-rates  and 
special  death-rates  based  on  population  of  less  than  100,000,  for 
the  errors  are  multiplied  when  the  population  of  the  given  place  is 
multiplied.  Suppose,  for  example,  a  city  of  10,000  population  has 
two  or  three  scattered  cases  of  typhoid  fever  each  year,  and  in 
1916  there  was  one  death,  the  first  in  five  years.  The  death-rate 
would  be  ten  times  the  number  of  deaths,  or  10  per  100,000, 
About  10  per  cent,  of  typhoid  cases  die,  and  the  number  of  cases 
is  usually  assumed  to  be  ten  times  the  number  of  deaths.  If 
the  death-rates  and  case-rates  were  published  on  the  basis  of 
100,000  population,  the  city  would  get  a  typhoid  reputation 
which  would  be  wholly  undeserved.  Still,  it  is  often  desirable 
for  a  health  officer  to  calculate  the  death  and  morbidity  rates 
for  the  various  diseases  in  his  district  in  order  that  he  may  com- 
pare them  with  those  of  the  rest  of  the  state  or  country. 


CHAPTER  XI 
PUBLIC  HEALTH  NURSING 

The  Individual  vs.  the  Public. — The  health  officer  works  for 
the  benetit  of  the  municipality  as  a  whole,  and  imposes  restraints 
on  individuals  for  the  protection  of  the  community.  He  often 
compels  those  who  feel  well  and  strong  to  stay  at  home,  and  he 
enforces  cleanliness  in  backyards  which  few  can  see.  Since  he 
causes  temporary  inconvenience  and  discomfort  to  individuals, 
he  is  often  considered  to  be  an  enemy  rather  than  a  friend,  and 
his  orders  are  obeyed  under  protest.  The  person  under  restric- 
tion frequently  does  not  understand  why  he  should  be  singled 
out  for  restraint,  and  the  health  officer  has  no  time  to  make  long 
explanations  of  the  reasons  to  him  or  to  sympathetic  friends  who 
consider  him  to  be  the  victim  of  official  wrath.  For  every  min- 
ute he  spends  in  the  discharge  of  his  scientific  duties  the  success- 
ful health  officer  must  spend  an  hour  in  the  social  and  educa- 
tional work  of  explaining  the  reasons  for  his  requirements,  and 
of  persuading  the  affected  persons  to  submit  voluntarily  to  his 
suggestions.  The  lack  of  this  educative  and  persuasive  work, 
which  a  public  health  nurse  can  best  supply,  is  the  reason  for 
the  failure  of  many  public  health  activities. 

Cure  or  Prevention. — Two  weak  points  in  public  health  ad- 
ministration were  formerly  that  it  was  concerned  only  with  epi- 
demics and  nuisances  that  were  already  fully  developed,  and 
that  the  corrective  measures  were  directed  against  those  only 
who  were  immediately  concerned  in  the  unhealthful  conditions. 
The  science  of  modern  public  health  is  often  called  preventive 
medicine.  It  seeks  the  premonitory  signs  of  impending  danger, 
and  considers  that  every  person  in  the  community  is  in  need 
of  instruction  and  oversight.  It  detects  the  smoldering  sparks 
of  infection  before  they  break  into  flame.  It  removes  the  rub- 
bish of  unhygienic  habits  and  unsanitary  surroundings  on  which 
contagion  feeds,  and  it  makes  each  individual  proof  against  the 
consuming  fires  of  disease.  The  work  of  suppressing  actual 
epidemics  and  nuisances  will  require  only  a  small  part  of  the 
time  of  the  average  health  officer,  but  the  elimination  of  the 
conditions  out  of  which  they  develop  will  require  his  full-time 
service,  or  that  of  an  assistant.  Public  health  nursing  is  an 
activity  that  has  been  developed  for  doing  many  of  the  details 


PUBLIC  HEALTH  NURSING  113 

of  this  preventive  work.  The  nurse  is  displacing  the  policeman 
as  the  health  officer's  chief  assistant.  A  municipality  of  3000 
inhabitants  will  have  abundant  work  to  keep  a  public  health 
nurse  busy. 

The  public  health  laws  usually  empower  a  health  officer  to 
control  only  those  persons  who  are  afflicted  with  or  exposed 
to  certain  communicable  diseases  (New  York  State  Public 
Health  Law,  Sec.  25).  His  police  powers  are  strictly  limited 
to  the  control  of  the  sick  and  those  in  contact  with  them,  but  his 
educational  and  advisory  powers  are  unlimited  and  the  field  for 
their  exercise  is  boundless.  He  will  attend  to  the  police,  med- 
ical, and  scientific  work  in  the  homes  of  the  sick;  while  the  public 
health  nurse  will  be  his  agent  in  the  homes  of  those  who  are  com- 
paratively well.  Her  duties  will  be  largely  educational  and 
advisory  to  those  who  through  poverty,  ignorance,  or  prejudice 
would  not  otherwise  receive  the  benefits  of  modern  preventive 
medicine. 

Need  for  a  Public  Health  Nurse. — About  one-quarter  of  the 
people  are  without  regular  medical  advisors.  They  call  a 
physician  only  when  they  are  sick  abed,  and  drop  him  as  soon 
as  they  can  sit  up.  They  neglect  conditions  which  are  painless, 
and  believe  they  will  outgrow  ordinary  chronic  complaints. 
They  overlook  physical  defects  which  lead  to  permanent  disabil- 
ity or  incompetence.  They  live  amid  unsanitary  surroundings, 
and  practice  unhygienic  habits  which  render  them  easy  victims 
to  contagious  diseases.  They  are  often  without  ambition,  and 
accept  their  condition  and  station  in  life  as  inevitable.  Many 
are  contented  with  their  state  and  desire  nothing  better.  The 
preventable  physical  defects  and  many  of  those  conditions  which 
may  be  remedied  by  social  agencies  come  under  the  jurisdiction 
of  the  health  officer.  A  public  health  nurse  is  needed  to  look 
after  the  victims  while  their  defects  are  in  a  remediable  stage. 
Her  work  is  to  educate,  advise,  encourage,  and  inspire  the  suf- 
ferers and  those  who  are  responsible  for  their  welfare.  She 
arranges  for  their  medical  attention,  and  teaches  them  the  proper 
methods  of  home  care.  She  persuades  them  to  submit  to  the 
diagnostic  procedures  of  the  health  department,  to  accept  pro- 
phylactic vaccines  and  serums,  and  to  adopt  active  preventive 
measures  against  infections.  She  takes  the  sufferers  to  clinics 
and  hospitals,  and  acts  as  their  friendly  guide  and  counselor. 

Physicians  are  usually  willing  to  donate  their  medical  and 
surgical  services  to  those  in  need,  provided  they  do  not  have 
the  bother  of  persuading  them  to  undergo  examinations  and  to 
follow  advice  intelligently  and  willingly.  The  nurse  is  the  field 
agent  of  the  physicians  and  the  health  officer.     She  makes  the 


114  THE   HEALTH    OFFICER 

preliminary  arrangements  for  examinations  and  operations,  at- 
tends to  the  follow-up  inspections,  and  sees  that  instructions  are 
carried  out.  She  makes  it  possible  for  physicians  to  give  their 
services  \yith  a  fair  prospect  that  those  who  receive  them  will 
be  permanently  helped.  She  is  almost  indispensable  in  the 
practice  of  preventive  medicine. 

Many  communities  employ  visiting  nurses  to  care  for  the 
sick  poor  to  whom  they  are  called  by  physicians.  A  visiting 
nurse  does  the  actual  work  of  nursing,  has  only  a  few  cases  at 
a  time,  and  spends  a  considerable  tmie  with  each  case.  She  is 
an  assistant  to  private  physicians,  and  does  httle  else  than  bed- 
side work.  In  contrast  with  her  duties,  the  public  health  nurse 
does  preventive  work.  She  does  not  nurse  private  cases  for 
physicians  except  in  emergencies,  and  then  only  until  other 
care  can  be  provided.  She  deals  with  those  who  require  a  phy- 
sician's services  only  infrequently,  but  who  do  require  oversight, 
instruction,  and  encouragement  over  considerable  periods  of 
time.  She  has  a  large  number  of  persons  under  observation 
and  instruction  at  one  time,  and  refers  each  one  to  the  health 
officer 'or  physician  at  infrequent  intervals.  She  deals  prin- 
cipally with  children  in  whom  defects  may  be  permanently 
remedied,  provided  the  proper  home  treatment  is  given  or 
hygienic  measures  are  followed.  Although  she  depends  on  phy- 
sicians for  diagnoses  and  for  suggested  treatments,  most  of  her 
work  is  done  independently  of  them.  Her  work  is  entirely  dif- 
ferent from  that  of  the  visiting  nurse,  and  their  activities  overlap 
only  occasionally.  There  is  need  for  both  a  visiting  nurse  and 
a  public  health  nurse  in  every  city  and  large  village. 

Qualifications. — A  public  health  nurse  must  be  a  graduate 
nurse  with  some  practical  experience  outside  of  her  school. 
She  must  be  able  to  recognize  the  common  defects  and  diseases, 
and  to  know  the  usual  methods  of  their  treatment.  It  is  not 
within  the  scope  of  her  work  to  make  diagnoses  and  to  suggest 
treatments,  for  that  is  the  work  of  the  health  officer  and  the 
physicians  to  whom  she  refers  the  cases.  But  she  is  expected 
to  be  correct  in  her  surmises,  and  to  ask  the  physicians  to  diag- 
nose and  treat  only  those  in  whom  there  is  a  reasonable  prospect 
of  finding  a  serious  condition.  She  must  avoid  practising  med- 
icine or  assuming  any  of  the  prerogatives  of  a  physician;  and, 
on  the  other  hand,  she  must  not  overlook  serious  conditions. 
Nearly  every  person  claims  some  physician  as  a  family  adviser, 
and  it  is  the  duty  of  the  nurse  to  encourage  faith  in  him.  Many 
persons  have  lost  faith  in  all  physicians  largely  because  they 
cannot,  or  will  not,  or  do  not  give  either  money  or  gratitude 
for  the  advice  which  they  receive.    A  public  health  nurse  acts 


PUBLIC   HEALTH   NURSING  115 

as  the  agent  for  both  the  physicians  and  the  patients.  Her 
great  work  is  to  make  it  easy  for  physicians  to  advise  and  treat 
needy  patients,  and  for  the  patients  to  receive  efficient  medical 
assistance.  She  will  remove  the  misunderstandings  between  the 
people  and  medical  men.  Her  oversight  will  lead  physicians 
to  make  accurate  diagnoses  and  to  give  efficient  treatments. 
One  of  the  indirect  effects  of  a  public  health  nurse's  work  will 
be  to  raise  the  standard  of  medical  practice  in  a  community. 

A  pubHc  health  nurse  must  be  strong  physically,  for  she  has 
to  be  out  of  doors  in  all  kinds  of  weather  and  to  walk  consider- 
able distances. 

The  personality  of  a  pubHc  health  nurse  is  as  important  as 
her  knowledge  and  physical  vigor.  She  must  be  sociable,  and 
able  to  converse  readily  and  familiarly  with  all  classes  of  people. 
She  must  be  even  tempered  and  patient,  for  scolding  is  fatal  to 
her  success.  She  must  possess  a  high  degree  of  common  sense 
in  order  to  avoid  demanding  impossible  things.  She  must  be 
wilKng  to  render  assistance  in  any  capacity.  Above  all,  she 
must  be  womanly  and  sympathetic. 

The  standards  of  qualifications  of  a  public  health  nurse  are 
by  no  means  impossible  of  attainment.  The  rewards  of  gratitude 
which  she  receives,  and  the  consciousness  of  bringing  permanent 
help  to  the  needy,  make  the  work  attractive  to  a  nurse  who 
has  a  love  for  mankind  and  a  sincere  desire  to  render  pubhc 
service.  The  number  of  competent  public  health  nurses  keeps 
pace  with  the  constantly  increasing  demand  for  their  services. 

Methods  of  Work. — ^A  pubhc  health  nurse  works  in  homes, 
in  schools,  and  in  cHnics.  She  visits  from  house  to  house, 
talks  to  the  people,  and  decides  who  are  in  need.  She  seeks  cases 
to  whom  she  may  offer  her  services  and  those  of  physicians  and 
the  health  officer.  She  observes  home  conditions,  and  explains 
points  in  hygiene  and  sanitation  which  are  obvious  to  the  edu- 
cated and  refined,  but  which  are  practically  unknown  to  a  large 
proportion  of  the  people.  The  personal  work  which  she  does  in 
homes  upon  her  own  initiative  requires  the  greater  part  of  her 
time. 

The  public  health  nurse  also  works  in  schools.  She  observes 
the  children  and  discusses  their  condition  with  the  teachers. 
She  gives  some  treatments  and  advice  directly  to  the  children, 
but  the  most  effective  school  work  which  she  does  is  that  of  visit- 
ing the  parents  in  the  homes  of  the  needy  children.  The  school 
is  a  convenient  place  in  which  she  discovers  defective  children, 
but  she  does  most  of  the  work  of  treating  and  correcting  their 
defects  in  their  homes. 

A  central  chnic  is  a  necessity  in  doing  pubhc  health  nursing. 


116  THE  HEALTH   OFFICER 

It  may  be  only  an  office,  or  it  may  be  a  fully  equipped  operating- 
room  with  wards  and  beds.  The  nurse  requires  some  place  to 
which  she  may  bring  cases  for  treatments  and  for  examinations 
by  physicians. 

The  method  of  work  which  a  nurse  follows  will  depend  on 
herself  and  on  the  needs  of  her  town.  A  competent  nurse  is 
expected  to  be  a  leader  and  to  adapt  her  methods  to  the  com- 
munity in  which  she  works.  If  the  work  has  been  previously 
developed,  or  if  she  is  one  of  many  nurses  in  a  large  city,  her  work 
will  be  systematized  and  laid  out  for  her;  but  in  a  small  com- 
munity she  will  plan  the  work  in  her  own  field,  just  as  the  health 
officer  is  the  leader  in  his  own  Kne  of  work. 

Activities. — Public  health"  nursing  is  rapidly  becoming  a  dis- 
tinct profession,  and  the  work  has  developed  along  five  standard 
lines:  1,  conmiunicable  diseases;  2,  tuberculosis;  3.  infant  wel- 
fare; 4,  child  hygiene;  5,  school  work.  Public  health  nurses  are 
also  employed  by  the  departments  of  health  of  states  and  large 
cities,  and  by  lay  societies,  to  conduct  special  investigations, 
supervise  midwives,  conduct  exhibits,  and  do  other  general  work. 

Communicable  Diseases. — When  an  outbreak  of  communi- 
cable disease  occurs,  many  mild  cases  will  be  missed  and  will 
remain  unknown  unless  search  is  made  for  them.  A  health 
officer  cannot  find  these  cases  without  a  house-to-house  canvass. 
The  public  health  nurse  is  the  proper  person  to  do  this  work. 
She  is  not  supposed  to  come  in  close  contact  with  severe  forms  of 
disease,  such  as  scarlet  fever  or  diphtheria,  for  if  she  did,  many 
persons  would  object  to  her  presence  in  their  homes.  Her  duty 
is  to  find  the  cases  and  to  report  them  to  the  health  officer,  who 
will  make  the  proper  disposition  of  them.  This  work  will  occa- 
sionally have  to  be  done  on  a  large  scale  during  an  epidemic; 
but  the  pubhc  health  nurse  will  maintain  a  constant  lookout  for 
mild  cases,  particularly  of  minor  diseases,  such  as  chickenpox, 
mumps,  and  whooping-cough. 

Tuberculosis. — Eft'ective  antituberculosis  work  cannot  be 
done  without  the  servdces  of  a  public  health  nurse.  There  is  a 
wide-spread  belief  that  consumption  is  always  a  fatal  disease. 
Incipient  cases  delude  themselves  with  the  belief  that  they  do 
not  have  the  disease.  They  stay  away  from  a  physician  until 
they  are  beyond  cure.  Advanced  cases  go  from  one  physician 
to  another  seeking  relief  with  pills  and  powders.  A  public 
health  nurse  is  needed,  first,  to  discover  cases,  and  second',  to 
advise  and  encourage  them  to  persevere  in  hygienic  measures. 
She  visits  suspected  cases  in  their  homes,  secures  their  examina- 
tion, supervises  their  treatment,  and  arranges  for  their  admis- 
sion to  clinics  and  hospitals.     She  is  their  friend  and  confidant. 


PUBLIC  HEALTH   NURSING  117 

She  comforts  the  advanced  cases,  and  encourages  the  incipients 
with  the  assurance  of  relief.  She  educates  the  people  of  a  com- 
munity in  the  meaning  of  a  cough  and  of  loss  of  weight  and 
strength,  and  demonstrates  to  them  that  tuberculosis  is  curable 
and  preventable.  All  this  work  requires  constant  visitation  and 
supervision.  There  are  at  least  10  or  20  cases  of  tuberculosis 
among  each  1000  inhabitants,  and  experience  shows  that  they 
will  not  place  themselves  in  the  care  of  physicians  unless  they 
are  constantly  urged  by  a  public  health  nurse  or  a  similar  worker. 
The  efficiency  of  a  public  health  nurse  may  be  judged  by  the 
quality  and  quantity  of  tuberculosis  work  which  she  does.  A 
pubhc  health  nurse  in  every  community  will  be  the  principal 
means  by  which  tuberculosis  will  be  eradicated. 

Infant  Welfare. — The  great  reduction  of  death-rates  in  civil- 
ized lands  in  recent  years  has  been  principally  among  infants 
and  young  children.  One  of  the  greatest  factors  in  life  saving 
among  babies  has  been  the  education  of  mothers,  especially  in 
cities  and  in  congested  sections  of  villages.  The  work  has  been 
carried  on  principally  by  pubhc  health  nurses.  They  visit 
homes  and  demonstrate  methods  of  bathing  and  feeding,  the 
pasteurization  and  preservation  of  milk,  the  clothing  of  the 
children,  and  the  ventilation  of  the  rooms.  They  establish  and 
conduct  milk  stations  and  infant  welfare  centers  in  which  care 
is  given  to  the  babies  and  instruction  to  their  mothers.  They 
give  advice  and  attention  to  expectant  mothers  and  secure  the 
co-operation  of  midwives  and  practical  nurses  in  the  proper 
care  of  the  infants  in  their  charge.  This  work  has  reduced  the 
infant  mortality  in  New  York  City  in  a  generation  from  nearly 
300  per  1000  to  less  than  100.  There  is  a  field  for  this  work  in 
every  community. 

Child  Hygiene. — The  Health  Department  of  New  York  City 
plans  that  a  public  health  nurse  shall  supervise  every  needy  child 
from  birth  to  adolescence.  She  works  among  children  of  pre- 
school age  in  connection  with  her  infant  welfare  activities,  but 
most  work  in  child  hygiene  everywhere  is  done  through  the 
schools.  Child  hygiene  is  concerned  largely  with  the  health  of 
the  school  child. 

School  Work. — The  supervision  of  the  health  of  school  chil- 
dren and  the  correction  of  their  defects  is  rapidly  becoming  the 
recognized  duty  of  every  department  of  health.  Many  states 
require  the  medical  examination  of  every  school  child,  but  an 
examination  has  no  value  unless  the  means  are  provided  for 
correcting  the  defects.  A  physician  cannot  spend  the  time  to 
visit  the  parents  of  every  defective  child,  explain  the  nature  of 
the  trouble,  persuade  them  to  have  corrections  done,  arrange  for 


118  THE    HEALTH    OFFICER 

the  treatments  and  operations,  and  follow  up  the  cases  afterward. 
This  is  peculiarly  the  work  of  a  public  health  nurse,  and  in  it 
she  has  the  assistance  of  the  teachers  and  the  support  of  the 
school  officers.  At  least  1  scholar  in  every  5  has  serious  defects 
of  the  teeth,  eyes,  ears,  or  other  organs  which  will  go  uncorrected 
unless  a  public  health  nurse  secures  their  correction.  One  of 
her  principal  activities  is  the  inspection  of  children  in  schools 
and  consultation  with  parents  in  their  homes  in  order  to  promote 
the  health  and  correct  the  defects  of  the  scholars. 

Relation  to  the  Health  Officer. — The  health  officer  is  the 
person  who  would  naturally  direct  the  work  of  a  public  health 
nurse,  but  if  he  is  unprogressive,  a  nurse  with  initiative  will 
soon  become  unpopular  with  him.  If  she  lacks  initiative,  he 
may  use  her  to  do  his  own  proper  work,  and  her  activities  will 
be  wasted.  But  frequently  a  philanthropic  society  or  civic  club 
will  employ  a  public  health  nurse  to  do  the  work  which  an  un- 
progressive health  "officer  is  expected  to  do.  Success  in  public 
health  nursing  requires  an  active  co-operation  between  the  health 
officer  and  the  nurse. 

Starting  the  Work. — A  public  health  nurse  is  one  of  the  most 
efficient  agencies  for  promoting  public  health  in  any  community, 
and  the  people  are  willing  to  support  one  when  the  value  of  her 
services  is  demonstrated  to  them.  If  it  is  desired  to  start  the 
work  of  pubhc  health  nursing,  a  practical  method  is  that  the 
health  officer  take  advantage  of  an  epidemic  and  secure  the 
consent  of  his  board  of  health  to  employ  a  public  health  nurse 
to  make  a  house-to-house  canvass  of  the  affected  district.  While 
she  discovers  cases  of  the  particular  disease  which  she  seeks,  she 
will  also  obser\'e  unhygienic  houses,  cases  of  tuberculosis,  de- 
fective children,  and  neglected  cripples.  If  she  is  successful  in 
the  control  of  the  epidemic,  the  people  will  be  favorably  inclined 
toward  her  plan  for  the  future  work  which  she  will  base  on  her 
obser^'ations.  The  next  step  would  be  that  a  public-spirited 
citizen  or  committee  provide  her  salary  for  a  brief  period,  with 
the  understanding  that  the  board  of  health  and  the  health 
officer  will  make  her  an  official  of  the  department  of  health; 
or  that  the  board  of  education  will  authorize  her  to  work  in  the 
schools.  A  reasonable  expectation  is  that  at  the  end  of  a  few 
weeks  or  months  the  people  will  see  the  value  of  her  services  and 
will  vote  the  funds  for  her  permanent  emplojTnent. 


CHAPTER  XII 
PUBLICITY  AND  EDUCATION 

Basis  of  Public  Health  Work. — Public  health  activities  may 
be  divided  into  two  classes  of  work — those  which  deal  with 
private  persons  and  those  which  deal  with  the  public  collectively. 
Most  contagious  disease  work  is  done  with  individuals.  Ex- 
amples of  activities  which  deal  with  the  public  collectively  are 
municipal  sewage  disposal,  milk  inspection,  and  dairy  permits. 
But  even  those  activities  which  deal  with  the  public  collectively 
depend  upon  the  attitude  of  a  majority  of  the  private  citizens 
of  a  community.  The  American  system  of  public  health  ad- 
ministration is  founded  upon  the  principle  of  individual  freedom 
and  responsibihty.  Public  sentiment  is  the  average  sentiment 
of  a  majority  of  the  individual  inhabitants.  The  fundamental 
health  laws  represent  the  opinions  and  desires  of  a  majority 
of  the  voters  of  the  several  states.  The  kind  of  work  which  a 
health  officer  can  do  will  be  that  which  a  majority  of  the  people 
wishes  to  have  done.  For  example,  the  estabhshment  of  a  sewer 
district  in  a  town  in  New  York  State  requires  the  signed  consent 
of  51  per  cent,  of  the  taxpayers  of  the  district,  and  in  a  village 
the  affirmative  vote  of  a  majority  of  the  taxpayers. 

The  basis  of  the  more  public  phases  of  health  department 
work  is  the  personal  hygiene  of  the  individual.  Every  person 
affects  a  great  circle  of  other  persons,  and  the  personal  careless- 
ness or  ignorance  of  one  may  spread  disease  through  a  whole 
community.  For  example,  an  epidemic  of  septic  sore  throat  is 
usually  traceable  to  a  single  dairyman  who  has  a  mild  sore  throat. 
It  is  impossible  for  a  health  officer  to  make  a  daily  inspection 
of  every  workman  in  every  dairy  in  his  jurisdiction.  The  pre- 
vention of  septic  sore  throat,  therefore,  depends  upon  the  per- 
sonal hygienic  habits  of  the  individual  workmen  in  dairies. 

The  prevention  of  smallpox  is  another  example  of  the  de- 
pendence of  public  health  work  on  the  attitude  of  individuals. 
Vaccination  in  most  health  ofi&cer  districts  is  not  compulsory, 
but  is  done  or  not  according  to  the  choice  of  the  indi\ddual.  If 
80  per  cent,  of  the  people  choose  to  be  vaccinated,  an  epidemic 
of  smallpox  is  not  likely  to  develop.  The  individuals  belonging 
to  the  20  per  cent,  who  refuse  vaccination  are  dependent  on  their 
neighbors  for  their  protection  against  the  disease.     Whether  or 

119 


120  THE   HEALTH    OFFICER 

not  a  community  is  threatened  with  smallpox  depends  upon  the 
feelings  and  knowledge  of  the  individuals  of  that  community. 

The  examples  which  have  just  been  given  illustrate  the  need 
of  educating  each  individual  person  in  public  health  matters. 
There  is  constant  progress  in  the  sciences  of  hygiene  and  sanita- 
tion, but  a  health  officer  frequently  encounters  a  satisfaction 
with  the  old,  an  opposition  to  the  new,  and  an  incredulity  regard- 
ing the  benefits  of  the  modern  order  in  public  health.  The  edu- 
cation of  the  public  is  one  of  the  recognized  duties  of  every  health 
officer,  and  is  written  into  the  pubhc  health  law  of  New  York 
State  (Sec.  21b). 

Sources  of  Popular  Knowledge. — A  health  officer  finds  that 
people  have  fairly  uniform  and  definite  ideas  regarding  hygiene 
and  sanitation,  showing  that  they  think  on  these  matters,  al- 
though their  conclusions  may  be  antiquated  and  erroneous.  For 
example,  he  finds  that  every  child  who  is  supposed  to  have 
measles  is  in  a  dark,  hot,  close  room,  and  is  covered  with  thick 
bedclothes  in  order,  as  the  parents  say,  to  protect  the  child's 
eyes,  to  keep  it  from  taking  cold,  and  to  makes  the  measles  come 
out.  One  great  source  of  these  popular  ideas  is  unwritten  tradi- 
tion preser\'ed  in  memory  and  handed  down  by  word  of  mouth, 
as  in  the  days  of  Homer.  The  traditions  represent  the  teachings 
of  advanced  physicians  who  lived  a  generation  or  two  ago.  It 
ordinarily  takes  a  generation  of  time  for  knowledge  of  new 
health  principles  to  permeate  the  thoughts  of  the  whole  mass 
of  people.  One  of  the  great  problems  in  public  health  adminis- 
tration is  how  to  hasten  the  dispersion  of  a  knowledge  of  recent 
advances  in  public  health. 

Physicians  constitute  another  source  from  which  people  get 
their  ideas  of  hygiene  and  sanitation;  but  their  influence  for 
progress  is  often  curtailed  by  their  acquiescence  in  the  opinions 
of  their  patients.  They  often  say  they  will  vaccinate  if  the  pa- 
tient wishes  them  to  do  so.  They  frequently  agree  with  a  pa- 
tient's own  diagnosis  that  he  has  taken  cold  on  his  bowels  and 
is  merely  threatened  with  tjphoid  fever.  Easy-going  phy- 
sicians are  largely  responsible  for  the  persistence  of  many  dis- 
credited medical  ideas  among  the  laity.  A  health  officer  must 
include  the  physicians  among  those  who  need  education. 

The  newspapers  are  a  third  source  of  popular  knowledge  in 
hygiene  and  sanitation.  The  function  of  a  newspaper  is  to  print 
the  news.  It  is  news  that  a  group  of  faddists  discusses  the 
relation  of  smallpox  to  diet  and  advocates  the  use  of  nuts  as  a 
preventive  measure.  If  there  are  ten  meetings  of  various  fad- 
dists, and  one  of  a  medical  society,  the  readers  of  the  newspaper 
will  get  ten  erroneous  impressions  to  one  of  scientific  medicine. 


PUBLICITY   AND    EDUCATION  121 

When  an  epidemic  is  going  on,  the  statements  of  the  health  officer 
soon  become  commonplace,  and  cease  to  have  a  news  value, 
while  every  new  faddist  that  comes  to  town  is  exploited  for  a 
brief  period.  If  there  are  ten  faddists,  the  readers  of  the  news- 
paper get  the  impression  that  the  health  officer  is  only  one-tenth 
as  important  a  personage  as  he  should  be.  The  city  daily  news- 
papers and  country  weeklies  have  a  tremendous  effect  in  educat- 
ing the  public  in  health  matters,  and  a  health  officer  must  in- 
clude them  among  his  helpers  in  educational  work. 

The  public  school  is  a  fourth  source  of  knowledge  in  public 
health  matters.  Too  much  is  often  expected  from  school  in- 
structions in  sanitation,  and  there  is  much  unjust  criticism  of  the 
failure  of  older  persons  to  understand  modern  methods  of  public 
health  work.  The  school  lessons  are  comparatively  few,  and 
the  instruction  is  interrupted  and  spread  over  years.  The  aver- 
age teacher  is  necessarily  at  least  five  years  behind  the  progres- 
sive sanitary  knowledge  of  the  hour.  The  science  of  public 
health  becomes  almost  entirely  changed  during  the  ten  years 
in  which  the  child  is  attending  school  from  the  age  of  seven  to 
seventeen,  and  the  knowledge  becomes  still  more  out  of  date 
within  a  few  years  after  a  child  leaves  school.  But  the  school 
can  teach  the  elementary  principles  of  physiology,  anatomy, 
and  infection,  and  thus  give  the  pupil  a  foundation  knowledge 
which  will  enable  him  to  understand  public  health  articles  and 
lectures.  The  medical  inspection  of  school  children  and  physical 
training  are  bringing  pubhc  health  to  the  people  in  a  concrete, 
personal  way. 

The  activities  of  health  departments  constitute  a  fifth  source 
from  which  a  knowledge  of  public  health  matters  is  spread  among 
the  people.  The  local  departments  of  health  educate  the  peo- 
ple through  the  reports  of  their  meetings,  and  the  rules  and  regu- 
lations which  they  adopt.  Health  officers  promote  education  by 
means  of  their  reports  and  inspections.  State  departments  of 
health  distribute  literature  and  promote  lectures  and  exhibits. 
Many  state  departments  have  organized  divisions  w^hose  object 
is  to  spread  a  knowledge  of  health  matters  among  the  people. 
The  direct  efforts  of  departments  of  health  are  among  the  chief 
means  of  spreading  a  knowledge  of  modern  public  health  and 
preventive  medicine,  and  of  securing  the  co-operation  and  sup- 
port of  all  the  people  in  pubhc  health  work. 

The  Health  Officer  as  a  Teacher. — Ignorance  of  modem 
pubhc  health  work  is  not  confined  to  the  illiterate,  but  it  is  vdde- 
spread  even  among  the  college  graduates.  The  most  difficult 
people  with  whom  a  health  officer  has  to  deal  are  the  educated 
whose  knowledge  of  preventive  medicine  is  that  of  a  generation 


122  THE    HEALTH    OFFICER 

or  two  ago.  Some  of  the  vital  topics  in  which  all  classes  of  peo- 
ple show  a  wide-spread  ignorance  are  the  nature  of  colds,  the 
infectiousness  of  summer  complaints,  the  danger  from  healthy 
carriers,  the  nature  of  contact  infection,  the  principles  of  ventila- 
tion, the  purity  of  night  air,  the  value  of  antitoxins  and  serums, 
the  need  and  harmlessness  of  blood  examinations  and  spinal 
punctures,  and  the  prevalence  and  recognition  of  mild  cases  of 
major  contagious  diseases. 

State  departments  of  health  may  provide  the  means  for  com- 
bating disease  and  promoting  health,  but  if  the  people  refuse  to 
use  them,  they  will  be  of  no  avail.  One  of  the  most  important 
of  all  the  duties  of  a  health  officer  is  the  direct  education  of  the 
people  regarding  the  scientific  principles  on  which  his  activities 
are  founded.  The  efficiency  of  a  health  officer  may  be  gaged 
by  his  success  in  educating  the  people  and  securing  their  co- 
operation. Secrecy  and  mystery  have  no  place  in  public  health 
work.  It  is  necessary  that  every  health  officer  shall  be  a  teacher 
and  shall  have  in  mind  his  duty  to  educate  the  people  at  every 
opportunity.  The  successful  health  officer  will  create  public 
sentiment  if  he  does  not  find  it  ready  made. 

Publicity  and  Education. — The  educational  work  of  a  health 
officer  consists  in  publicity  regarding  the  scope,  objects,  methods, 
and  results  of  his  acti\ities,  and  in  education  regarding  the 
scientific  principles  on  which  his  work  is  based.  The  natural 
instincts  and  training  of  a  conscientious  physician  impel  a  health 
officer  to  avoid  publicity,  but  he  must  remember  that  he  is  the 
medical  adviser  of  the  public,  and  that  giving  advice  to  the 
people  wiU  result  in  spreading  information  through  the  whole 
community.  A  health  officer  is  a  public  officer,  and  the  very 
nature  of  his  work  requires  him  to  make  it  known.  The  people 
will  not  respond  to  appeals  which  never  reach  them.  jModesty 
is  commendable  when  it  restrains  a  health  officer  from  talking 
about  himself,  but  it  is  not  a  virtue  when  it  leads  him  to  avoid 
publicity  in  regard  to  his  work.  Publicity  is  necessary  in  health 
officer  work. 

Simplicity  of  Language.— A  health  officer  often  fails  in  giving 
instruction  because  he  uses  an  unknown  language  in  talking  with 
people.  If  he  gives  orders  in  words  which  his  hearers  do  not 
comprehend,  he  will  fail  to  obtain  obedience.  The  people  need 
ideas,  and  not  long  words.  Medical  terms  give  an  ignorant 
man  the  impression  that  the  diseases  to  which  they  apply  are 
as  foreign  as  the  words;  but  explanations  given  with  short, 
simple  words  which  he  understands,  dispel  the  mystery  of  dis- 
ease, and  at  once  excite  the  hearer's  interest  in  the  sickness.  A 
fundamental  rule  in  speaking  or  writing  is  to  use  words  which 


PUBLICITY   AND    EDUCATION  123 

the  hearers  and  readers  will  understand  without  effort.  Dis- 
eases and  public  health  matters  can  be  explained  with  simple 
words  which  are  used  in  ordinary  conversation.  For  examj)]e: 
The  expression,  an  injection  of  the  mucous  membrane  of  the 
pharynx  means  simply  a  redness  of  the  throat;  enlargement  of 
the  cervical  glands  means  a  swelling  of  the  glands  of  the  neck ; 
infective  organisms  invaded  the  tissues  means  that  disease  germs 
entered  the  flesh;  a  negative  examination  means  that  nothing 
was  found;  the  respiratory  passages  are  the  breathing  tubes; 
to  administer  a  medicine  means  to  give  it;  and  degeneration 
means  a  weakness  or  inactivity  of  a  part.  Most  persons  will 
not  understand  the  technical  terms  without  a  considerable 
mental  effort  or  the  use  of  a  dictionary,  but  even  the  illiterate 
will  understand  common  terms  and  simple  explanations. 

Campaigns  for  Special  Objects. — A  board  of  health  usually 
follows  public  sentiment,  and  enlarges  the  scope  of  its  work 
only  when  there  is  a  public  demand  for  the  action.  The  employ- 
ment of  a  public  health  nurse,  or  the  establishment  of  a  tuber- 
culosis sanatorium,  or  the  construction  of  a  sewer  system,  or  the 
adoption  of  any  new  line  of  work  usually  requires  a  majority 
vote  of  the  people,  which  can  be  obtained  only  after  a  campaign 
of  publicity  and  education.  The  health  officer  is  the  person  who 
would  naturally  be  the  leader  in  the  campaign.  If  he  is  not 
an  organizer  and  administrator,  he  will  still  be  expected  to  con- 
tribute his  time  and  thought  in  promoting  the  new  work.  When- 
ever a  campaign  for  a  special  object  is  conducted,  the  educa- 
tional influence  is  felt  in  all  other  hues  of  pubHc  health  work. 
The  great  progress  in  public  health  work  in  recent  years  has 
sprung  largely  from  the  extensive  antituberculosis  campaigns  of 
education  which  have  been  conducted  aU  over  the  United  States. 

Clinical  Talks  to  the  Laity. — One  of  the  simplest  and  most 
efficient  forms  of  pubHc  health  work  which  a  health  ofiicer  can 
do  consists  of  talks  to  individuals  whom  he  visits  officially. 
Every  case  of  communicable  disease  which  is  reported  to  him 
provides  him  with  a  subject  and  with  an  audience  to  whom  he  is 
expected  to  explain  the  nature  and  source  of  the  disease  and 
the  method  of  preventing  its  spread.  The  audience  is  in  a 
receptive  mood,  and  is  intensely  and  vitally  interested  in  what 
he  says.  The  people  in  the  surrounding  houses  are  both  curious 
and  anxious,  and  his  orders  and  instructions  will  be  repeated 
to  a  wide  circle  of  the  neighbors  and  relatives  of  the  sick  person. 
A  health  officer  who  merely  tacks  up  a  quarantine  card  or  sends 
an  inspector  to  do  it,  misses  a  great  opportunity  to  spread  a 
knowledge  of  the  nature  and  prevention  of  communicable  dis- 
eases. 


124  THE   HEALTH    OFFICER 

Every  inspection  of  a  nuisance  affords  an  opportunity  to 
explain  the  bearing  which  the  condition  may  have  on  health 
and  life.  When  people  understand  the  sources  of  danger  from 
dirt  and  decaying  matter,  they  will  not  be  likely  to  rush  to  the 
health  officer  with  unnecessary  complaints.  If  every  health 
officer  took  pains  to  educate  the  people  with  whom  he  deals, 
the  mass  of  people  would  become  educated  within  a  few 
years. 

Reports. — The  formal  reports  of  a  health  officer  have  a 
great  educational  value  when  their  data  are  complete  and  com- 
prehensive, and  the  bearing  of  the  facts  on  public  health  is  ex- 
plained. The  people  of  every  rural  community  glory  in  their 
low  death-rate,  the  old  age  to  which  the  people  live,  and  the 
absence  of  contagious  diseases,  except  the  cases  which  are  im- 
ported. These  facts  mean  nothing  in  themselves.  Every  com- 
munity has  public  health  problems,  and  its  healthfulness  needs 
improvement.  A  health  officer  who  understands  the  meaning 
and  use  of  a  report  can  make  it  an  effective  means  of  educating 
the  people;  but  even  a  dry,  formal  report  has  a  publicity  value 
in  showing  that  the  health  officer  is  alert  and  active. 

Newspapers. — The  newspapers  of  a  town,  village,  or  small 
city  are  valuable  means  of  publicity  and  education  which  a 
health  officer  can  use.  He  is  a  source  of  news  which  editors 
value.  Editors  are  usually  glad  to  print  reports  of  the  activities 
of  the  local  health  department,  and  to  give  publicity  to  its  plans 
for  future  work.  They  will  use  scientific  articles  which  are 
written  in  a  clear,  simple  style.  They  will  print  editorials  on 
the  work  of  the  health  officer,  and  while  the  comments  may  not 
always  be  complimentary,  yet  the  opposition  of  the  editors  is 
usually  inspired  by  a  dislike  of  the  health  officer  personally  rather 
than  to  a  desire  to  oppose  progress  in  health  matters. 

A  health  officer  is  often  under  a  great  temptation  to  engage 
in  personal  controversies  in  the  newspapers.  Public  health 
work  requires  the  co-operation  of  all  classes  of  people,  and  pub- 
lic criticism  of  any  person  is  sure  to  arouse  the  antagonism  of  a 
large  circle  of  that  person's  friends.  But  if  a  health  officer  will 
studiously  avoid  personal  disputes,  and  will  endure  public 
criticisms  of  himself  in  silence,  he  will  find  the  newspapers  to 
be  his  aids  in  both  pubhcity  and  education. 

One  of  the  dangers  in  newspaper  publicity  is  that  of  exag- 
geration. If,  for  example,  a  proposition  to  build  a  sewer  is 
under  consideration,  there  will  be  a  great  tendency  to  exaggerate 
the  threatened  danger  of  epidemics  from  cesspools,  and  to 
minimize  the  difficulty  and  cost  of  maintaining  a  disposal  plant. 
Truthfulness  and  accuracy  are  essential  whenever  the  health 


PUBLICITY  AND   EDUCATION  125 

officer  gives  an  interview.  Bald  statements  are  often  dry  and 
produce  little  impression  on  the  minds  of  the  readers;  and,  on 
the  other  hand,  jokes,  slang,  and  alarmist  interviews  belittle 
his  statements.  When  a  health  officer  gives  an  interview,  it  is 
a  good  plan  for  him  to  request  the  reporter  to  rehearse  the  salient 
features  of  the  story  which  he  intends  to  write. 

It  is  often  a  question  how  much  information* a  health  officer 
may  properly  give  out.  Some  facts  cannot  be  disclosed  legally. 
An  editor  knows  more  than  he  is  allowed  to  print,  and  it  is  often 
necessary  that  he  have  unprintable  information  in  order  that 
he  may  make  an  article  truthful  and  diplomatic.  It  is  a  rule 
among  newspaper  men  to  respect  the  wishes  of  those  whom 
they  interview,  just  as  lawyers  and  physicians  respect  the  wishes 
of  those  who  consult  them.  A  health  officer  is  usually  per- 
sonally acquainted  with  the  editors  and  reporters  of  his  town, 
and  knows  whom  he  can  trust  with  information. 

An  editor  will  often  change  the  form  of  articles  and  the  word- 
ing of  interviews  in  order  to  make  them  conform  to  the  style  and 
policy  of  his  newspaper.  If  a  health  officer  wishes  to  print 
matter  to  which  the  editor  objects,  he  can  get  it  inserted  as  a 
paid  advertisement.  A  board  of  health  is  justified  in  spending 
money  for  paid  advertising  in  emergencies. 

Handbills  and  Posters. — A  health  officer  often  wishes  to 
spread  special  information  to  all  the  people  as  soon  as  possible. 
It  is  his  duty  to  give  prompt  information  to  the  people  regarding 
the  ways  and  means  of  carrying  on  a  new  line  of  work  and  of 
meeting  an  emergency  condition.  He  can  do  this  with  posters 
or  handbills  which  are  distributed  from  house  to  house,  or  are 
carried  home  by  school  children.  Some  of  the  subjects  with 
which  a  health  officer  may  deal  by  means  of  handbills  are  in- 
structions to  the  public  during  an  epidemic,  how  to  suppress 
ffies,  how  to  exterminate  mosquitoes,  and  what  to  do  with  dogs 
when  a  case  of  rabies  occurs. 

A  poster  or  handbill  must  be  brief  and  specific  in  order  that 
its  meaning  may  be  grasped  quickly  and  easily.  It  must  be 
printed  in  large  type  which  may  be  read  easily. 

Lectures. — Public  lectures  have  a  twofold  value — they  di- 
rectly instruct  those- who  attend  them,  and  reports  of  them  call 
attention  to  the  activities  of  the  local  board.  A  lecture  by  a 
prominent  sanitarian  gives  dignity  and  importance  to  local 
health  work.  If  a  health  officer  can  speak  or  write  an  address, 
he  will  find  an  occasional  lecture  to  be  of  great  value  in  impress- 
ing people  with  the  importance  of  his  work. 

Lantern-slide  illustrations  are  always  great  aids  in  produc- 
ing an  impression.     Especially  valuable  are  slides  of  local  scenes. 


126  THE   HEALTH    OFFICER 

Views  taken  before  and  after  action  by  the  local  authorities 
arouse  civic  pride  in  an  effective  way. 

^Moving  pictures  have  an  educational  value,  and  still  greater 
value  for  publicity  and  arousing  interest.  Their  proper  place  is 
subordinate  to  that  of  an  explanatory  lecture.  A  balanced  pro- 
gram consists  of  a  half-hour  instructive  address  followed  by  a 
half-hour  moving  picture. 

A  lecture  will  not  run  itself,  but  its  success  will  depend  on 
the  preliminary  arrangements.  A  health  officer  or  board  of 
health  can  seldom  make  one  a  success  without  the  co-operation 
of  an  organized  body  of  people.  It  is  usually  best  to  have  a 
lecture  under  the  auspices  of  a  civic  club,  Red  Cross  Society, 
or  other  organization  that  is  interested  in  public  health  or  social 
work.  The  roll  of  members  in  these  organizations  usually  in- 
cludes all  those  persons  who  would  be  Ukely  to  support  a  lecture, 
and  from  them  it  is  necessary  to  choose  a  responsible  committee 
of  arrangements. 

A  health  officer  can  obtain  assistance  in  making  up  a  program 
from  the  State  Department  of  Health,  and  from  various  organiza- 
tions, such  as  the  New  York  State  Charities  Aid  Association. 
j\Iany  of  the  state  departments  of  health  and  organizations 
maintain  bureaus  of  speakers,  and  provide  lantern  sUdes  and 
moving-picture  films,  and  even  send  out  prepared  lectures  for 
those  who  cannot  secure  the  services  of  experienced  speakers. 
It  is  usually  a  good  plan  to  include  a  local  worker  on  the  pro- 
gram. A  person  who  is  a  poor  speaker  may  be  a  most  efficient 
worker,  and,  after  all,  it  is  the  deeds  rather  than  the  words  of 
the  speaker  that  inspire  others  to  work. 

Having  decided  on  a  program  and  arranged  i(x  a  lecture 
hall,  the  next  thing  to  do  is  to  advertise  the  meeting.  A  lecture 
is  impossible  without  an  audience,  and  people  will  not  come 
unless  they  are  urged.  The  ordinary  handbills,  posters,  and  press 
notices  are  all  necessary,  but  they  will  not  usually  entice  an 
audience  unless  the  promoters  of  the  lecture  ask  their  friends  to 
attend. 

The  final  step  in  making  arrangements  for  a  lecture  is  to  see 
that  a  report  of  it  reaches  the  newspapers.  A  health  officer 
will  personally  invite  the  newspaper  men  to  attend  the  meeting, 
will  tell  them  the  important  points  of  the  lecture,  and  will  out- 
line the  work  which  will  be  begun  or  promoted  as  a  result  of  the 
lecture.  The  press  reports  are  necessary  in  order  to  apply  the 
lessons  of  the  lecture  directly  to  the  community. 

Exhibits. — Health  exhibits  are  prepared  by  the  departments 
of  health  of  states  and  the  larger  cities,  and  by  large  organiza- 
tions and  societies.     Small  exhibits  are  prepared  for  use  by  the 


PUBLICITY   AND   EDUCATION  127 

health  officers  of  small  places.  They  consist  of  charts,  cartoons, 
photographs,  and  models,  and  are  usually  associated  with  dem- 
onstrations and  lectures.  The  subjects  included  in  the  exhibit 
are  infant  care,  child  welfare,  the  diseases  of  adult  life,  mental 
hygiene,  tuberculosis,  milk,  flies,  mosquitoes,  and  other  topics 
in  public  health  work.  The  New  York  State  Department  of 
Health  plans  that  an  exhibit  shall  remain  in  a  health  officer's 
district  for  a  few  days  or  a  week,  and  that  classes  for  children 
and  lectures  for  adults  shall  be  conducted  in  connection  with 
it.  An  exhibit  is  often  made  the  basis  of  establishing  an  infant 
welfare  station,  or  a  tuberculosis  clinic,  or  other  organized  form 
of  popular  health  work. 

Each  exhibit  requires  the  use  of  a  hall  with  a  large  wall  space, 
and  the  attendance  of  a  laborer,  a  demonstrator,  and  lecturers. 
The  health  officer  will  arrange  for  an  exhibit  in  the  same  general 
way  that  he  would  promote  a  lecture. 


CHAPTER  XIII 
BACTERIOLOGY 

Micro-organisms. — Communicable  diseases  are  destructive 
processes  that  take  place  in  living  things,  and  are  somewhat 
similar  to  the  processes  of  fermentation  and  decay  that  take 
place  in  Hfeless  substances.  Each  communicable  disease  is 
caused  by  its  own  particular  poison,  or  virus,  which  enters  the 
body  from  the  outside.  A  disease  virus  has  three  peculiar  char- 
acteristics: 1,  Its  effects  do  not  depend  on  the  amount  introduced 
into  the  body,  for  a  microscopic  quantity  produces  as  much 
effect  as  an  amount  that  can  be  readily  weighed  or  measured. 
2,  A  period  of  days  elapses  between  the  entrance  of  the  virus 
into  the  body  and  the  first  signs  of  the  disease.  3,  The  virus 
does  not  exhaust  itself,  but  multiplies  many  milhonfold  in  the 
body  of  the  sick  person.  A  disease  virus,  therefore,  acts  like 
seed  planted  and  growing  in  the  li\dng  body.  A  mxicroscopic 
examination  of  viruses  shows  that  the  essential  element  in  some 
consists  of  bacteria,  which  are  usually  classed  as  plants,  and  in 
others  of  protozoa,  which  are  usually  classed  as  animals.  In 
still  other  viruses  no  organisms  at  all  can  be  seen  with  a  micro- 
scope. The  Kving  organisms  of  disease  are  popularly  called 
disease  germs.  About  1200  species  of  bacteria  are  known,  but 
only  about  50  species  will  grow  in  the  human  body  and  produce 
diseases.  Living  bacteria  are  the  principal  causes  of  decay  and 
fermentation.  A  study  of  micro-organisms,  especially  of  those 
which  produce  diseases,  is  called  bacteriology. 

Bacteria  are  named  according  to  their  shape.  Some  are 
round,  and  are  called  cocci;  some  are  rod-shaped,  and  are  called 
bacilli;  and  some  are  shaped  like  corkscrews,  and  are  called 
spirilli.  Bacteria  are  simple  in  structure,  and  the  various  parts 
of  a  single  organism  show  but  a  slight  variation  in  appearance. 
They  multiply  simply  by  each  organism  dividing  into  two. 
This  division  may  occur  as  often  as  every  half-hour,  and  each 
individual  organism  may  become  more  than  1,000,000,000,000 
in  twenty-four  hours. 

Some  protozoa  resemble  bacteria  in  appearance  and  method 
of  growth,  but  others  are  complicated  in  form  and  in  their  mode 
of  development. 

128 


BACTERIOLOGY  129 

The  visibility  of  disease  germs  depends  principally  on  their 
size.  They  are  so  small  that  an  oil-immersion  lens  is  needed  in 
order  to  discern  clearly  the  forms  of  most  bacteria  and  pro- 
tozoa. The  smaller  germs  under  the  highest  powers  of  the  micro- 
scope appear  like  minute  dots.  Other  germs  are  ultramicro- 
scopic  and  cannot  be  magnified  sufficiently  to  be  seen. 

The  size  of  disease  germs  is  usually  expressed  in  micro- 
millimeters,  one  of  which  equals  txtoo  millimeter,  or  about  ittt^tto 
inch.  A  micromiUimeter  is  called  a  micron,  and  is  represented 
by  the  character  n,  a  Greek  m.  The  smallest  visible  germs  are 
about  ^  micron  in  diameter,  which  is  about  the  length  of  a  wave 
of  light. 

The  size  of  bacteria  or  protozoa  may  also  be  indicated  roughly 
by  their  ability  to  pass  through  the  pores  of  filters  made  of  un- 
glazed  porcelain.  None  of  the  visible  bacteria  can  pass  through 
a  porcelain  filter,  but  some  of  the  ultramicroscopic  germs  will 
pass  through  a  filter  unchanged  in  their  ability  to  produce  dis- 
eases. Three  filterable  viruses  are  those  of  epidemic  polio- 
myehtis,  rabies,  and  yellow  fever.  The  germs  of  smallpox, 
scarlet  fever,  and  measles  have  not  been  discovered,  but  there 
is  some  evidence  that  they  are  ultramicroscopic  and  will  pass 
through  the  finest  known  filter. 

Bacteria  and  Disease. — All  the  higher  animals  are  afflicted 
with  communicable  diseases,  and  each  disease  is  caused  by  its 
own  particular  micro-organism.  Each  kind  of  disease  germ  has 
its  own  special  requirements  for  growth  which  must  be  met 
before  the  germ  can  flourish.  Each  kind  of  germ  will  usually 
grow  only  in  a  particular  species  of  animal  or  plant.  The  germs 
of  most  human  diseases  grow  naturally  only  in  human  bodies; 
but  there  are  exceptions  to  the  rule.  Tetanus,  rabies,  glanders, 
anthrax,  and  tuberculosis  are  diseases  of  lower  animals  whose 
germs  may  grow  in  human  beings  also. 

Disease  germs  must  reach  the  flesh  or  blood  before  they  can 
produce  a  disease.  Each  species  of  germ  grows  best  in  some 
particular  part  of  the  body.  Diphtheria  germs,  for  example, 
grow  mostly  in  the  throat.  The  germs  will  usually  be  found  in 
those  parts  of  the  body  that  are  inflamed. 

Bacteria  of  decay  and  fermentation  may  usually  be  found  on 
the  surface  of  the  body,  and  in  every  cavity  which  is  connected 
with  the  surface;  and  bacteria  that  produce  diseases  often  grow 
with  them.  Bacteria  are  found  on  the  skin  among  the  outer, 
dead  layers  of  epithehum;  in  the  openings  of  the  sweat-glands; 
in  the  saliva;  in  the  furry  coating  of  the  tongue;  in  the  cr}'pts 
of  the  tonsils;  in  the  folds  of  the  mucous  membrane  of  the  nose; 
and  in  the  stomach  and  intestine.     If  a  person  is  healthy,  no 


130  THE   HEALTH    OFFICER 

bacteria  or  disease  germs  can  be  found  in  a  closed  cavity  of  the 
body,  such  as  the  peritoneum,  pleura,  or  blood-vessels;  or  in 
the  blood;  or  in  the  living  llesh. 

Most  disease  germs  that  leave  the  body  escape  in  the  natural 
excretions- of  the  nose  and  throat  and  of  the  bowels  and  bladder. 
The  chief  problem  in  the  prevention  of  communicable  diseases 
is  to  prevent  these  excretions  from  entering  the  bodies  of  other 
persons. 

Disease  germs  may  be  carried  out  of  the  body  by  unnatural 
discharges,  such  as  those  from  sores  on  the  skin,  matter  from 
running  ears,  and  liquids  from  diseased  eyes.  Disease  germs 
are  not  given  off  from  a  healthy,  clean  skin,  or  with  the  breath  of 
quiet  breathing.  A  health  ofhcer  looks  for  the  source  of  nearly 
all  kinds  of  disease  germs  in  the  liquid  or  sohd  discharges  from 
diseased  persons.  Very  few  kinds  of  germs  of  human  diseases 
grow  naturally  outside  of  the  human  body.  Dirt,  filth,  and 
decaying  substances  will  not  produce  disease  germs  unless  the 
germs  from  a  diseased  person  or  animal  are  in  them. 

Persistence  of  Life. — Disease  germs  do  not  usually  remain 
alive  for  any  great  length  of  time  after  they  have  left  the  body, 
for,  like  other  living  things,  they  soon  perish  when  they  are 
removed  from  the  favorable  surroundings  under  which  they 
have  grown.  But  they  may  remain  alive  for  hours  or  days  if 
they  are  protected  against  the  five  destructive  agents — sunlight, 
dryness,  starvation,  cleanliness,  and  oxygen. 

Sunlight  is  a  great  destroyer  of  disease  germs,  for  it  has  a 
chemical  action  upon  them  just  as  it  is  destructive  to  the  tender 
skin  of  a  person  who  is  exposed  to  it.  Disease  germs  do  not 
survive  long  in  a  sunshiny  room  if  they  are  exposed  to  the  light; 
but  if  they  are  enclosed  in  a  mass  of  excretions,  such  as  phlegm 
from  the  throat,  the  sunlight  may  not  reach  them,  and  they 
may  survive  for  weeks  or  months. 

Drying  kills  most  disease  germs  within  a  few  minutes  or 
hours,  but  the  germs  may  sur\dve  for  days  in  damp  places, 
especially  in  darkness.  The  germs  of  tuberculosis  contain  a  wax 
which  tends  to  protect  them  against  dryness. 

After  disease  germs  leave  the  body,  they  are  usually  not  able 
to  obtain  a  proper  supply  of  food,  and  those  of  the  more  tender 
varieties  soon  die  of  star^-ation,  especially  when  they  are  also 
subjected  to  the  destructive  influences  of  drying  and  sunlight. 
When  food  supplies  and  moisture  begin  to  fail,  some  varieties 
go  into  a  resting  stage  and  remain  in  a  dry,  quiescent  state  for 
days  or  weeks,  but  they  may  resume  their  growth  when  condi- 
tions become  favorable  again. 

Bacteria  which  are  able  to  resist  starvation  and  drying  may 


BACTERIOLOGY  131 

be  found  in  dust  when  the  material  in  which  they  grow  is  cjricd 
and  ground  to  powder.  Bacteria  of  fermentation  and  decay- 
are  able  to  survive  in  dust,  and  are  found  in  the  air  so  commonly 
that  they  fall  on  every  object  and  start  decomposition  in  every 
decomposable  substance.  Two  common  dust-borne  germs  in 
which  a  health  officer  is  especially  interested  are  those  of  tuber- 
culosis and  septicemia. 

A  few  kinds  of  disease  germs,  such  as  those  of  tetanus  and 
anthrax,  make  special  provision  to  protect  themselves  from  dry- 
ness and  starvation  by  forming  what  are  called  spores.  When 
a  spore-forming  bacterium  becomes  somewhat  dry,  or  its  food  is 
nearly  exhausted,  it  may  condense  or  concentrate  its  soHd  sub- 
stance into  a  small  part  of  its  body,  and  in  this  state  it  may  sur- 
vive all  the  common  destructive  agents  of  nature  and  remain 
ahve  for  months,  and  be  ready  to  begin  its  growth  again  when 
conditions  become  favorable.  A  spore  is  analogous  to  the  seed 
of  a  flowering  plant.  The  principal  spore-bearing  disease  germs 
in  which  a  health  officer  is  interested  are  those  of  tetanus,  an- 
thrax, and  glanders. 

The  frequent  use  of  soapsuds,  scrubbing  brushes,  and  other 
means  of  cleanliness  removes  disease  germs  and  the  dirt  and 
filth  in  which  they  are  often  found,  and  thus  destroys  the  lives 
of  the  organisms.  Dirt  and  filth  are  universally  considered  to 
be  disease  producers,  and  cleanliness  the  great  disease  preventive. 
This  is  true  of  only  that  kind  of  dirt  which  contains  disease 
germs  derived  from  diseased  human  beings.  For  example,  fresh 
ashes  contain  no  disease  germs  at  all,  while  house  dirt  is  very 
likely  to  contain  them. 

Nature  has  an  effective  means  of  destroying  disease  germs 
in  decomposable  filth.  Wherever  masses  of  human  excretions  or 
other  forms  of  filth  are  found,  the  bacteria  of  decay  and  decom- 
position also  grow  luxuriantly,  and  produce  conditions  unfavor- 
able to  the  growth  of  the  disease  germs. 

Another  common  destroyer  of  disease  germs  is  an  excess  of 
oxygen.  Sunlight,  dryness,  cleanliness,  and  fresh  air  naturally 
go  together,  and  each  promotes  the  action  of  the  others.  Health 
officers  depend  on  these  four  things  more  than  on  any  others 
for  the  destruction  of  disease  germs  outside  of  the  human  body. 

The  time  element  must  be  considered  in  estimating  the 
effect  of  destructive  agents  on  bacteria.  If  the  destructive  agents 
act  on  disease  germs  for  only  a  short  time,  the  virulency  of  the 
germs  may  continue  unimpaired.  But  a  health  officer  w^ho 
applies  all  the  natural  agents  of  destruction  to  disease  germs  in 
a  thorough  manner  and  continuously  may  be  confident  that 
none  of  the  germs  will  escape  alive. 


132  THE  HEALTH   OFFICER 

Destruction  of  Bacteria. — Three  artificial  means  which  are 
used  to  destroy  disease  germs  are  the  disposal  of  excretions  from 
the  body,  chemical  antiseptics,  and  heat.  The  health  officer 
will  give  careful  and  specific  directions  that  the  excretions  from 
those  persons  who  have  contagious  diseases  shall  be  burned,  or 
buried,  or  otherwise  treated  in  such  a  way  that  they  and  the 
disease  germs  in  them  are  destroyed. 

Chemical  antiseptics  usually  act  by  coagulating  the  substance 
of  the  germs.  They  must  come  in  actual  contact  with  the 
germs,  and  must  remain  in  contact  with  them  for  at  least  a  few 
minutes.  Five  antiseptics  which  bacteriologists  and  health 
officers  frequently  use  are  alcohol,  formaldehyd,  bichlorid  of 
mercury,  carbolic  acid,  and  chlorid  of  lime. 

Alcohol  is  effective  in  cleansing  the  hands  either  in  the 
laboratory  or  in  the  sick  room.  Formaldehyd  is  excellent  for 
the  health  officer  to  leave  for  use  in  a  household  where  there  is 
a  contagious  disease. 

Heat  is  the  most  reliable  and  is  often  the  most  easily  applied 
of  all  antiseptics.  A  temperature  of  150°  F.  continued  for  fif- 
teen minutes  will  kill  nearly  all  kinds  of  disease  germs,  but  a 
boiling  temperature  (212°  F.)  continued  for  one-half  hour  is 
required  to  kill  the  spores  of  bacteria,  either  in  the  laboratory  or 
in  the  home. 

Effect  of  Low  Temperature. — The  temperature  at  which  dis- 
ease germs  flourish  best  is  that  of  the  human  body.  A  con- 
siderably lower  temperature  suspends  their  growth  without  in- 
juring the  germs.  A  temperature  below  freezing  continued  for 
weeks  will  kill  many  disease  germs.  The  common  bacteria  of 
decay  and  fermentation  cannot  multiply  at  temperatures  ap- 
proaching that  of  freezing.  This  principle  is  applied  in  the  pres- 
ervation of  foods  by  cold  storage. 

Cultures. — Disease  germs  seldom  multiply  naturally  outside 
of  a  living  body;  but  they  may  be  cultivated  and  grown  if  the 
conditions  which  they  require  for  growth  are  exactly  met.  A 
collection  of  disease  germs  growing  under  artificial  conditions  is 
called  a  culture.  Disease  germs  are  usually  studied  and  identified 
by  means  of  their  cultures. 

Cultures  are  grown  in  glass  vessels  which  are  usually  made 
in  the  form  of  test-tubes,  called  culture-tubes,  for  solid  media; 
and  of  bottles  or  flasks  for  liquid  media.  Shallow,  covered  dishes 
called  Petri  dishes  are  also  used  for  solid  media.  Health  officers 
generally  use  culture-tubes  for  taking  specimens  for  diagnosing 
diseases. 

The  three  conditions  which  are  necessary  in  obtaining  a 
growth  of  disease  germs  in  cultures  are  the  proper  temperature, 


BACTERIOLOGY  133 

moisture,  and  food-supply.  Disease  germs  grow  best  at  a  tem- 
perature of  about  98.5°  F.,  which  is  that  of  a  human  body. 
If  the  temperature  rises  a  few  degrees  above  100°  F.,  the  germs 
usually  die,  and  if  it  falls  much  below  100°  F.,  the  germs  lie 
quiescent  and  do  not  grow.  Growing  cultures  are  kept  in  a 
box,  called  an  incubator,  in  which  a  constant  temperature  can 
be  maintained  at  any  degree  that  may  be  desired.  An  ordinary 
incubator  for  hatching  hen's  eggs  may  be  used  in  emergencies 
as  an  incubator  for  growing  germs  in  a  culture. 

Disease  germs  require  a  considerable  quantity  of  moisture 
for  their  growth.  The  food  substances  in  culture-tubes  which 
health  officers  carry  in  stock  are  protected  from  evaporation  by 
a  rubber  cap  or  by  a  paraffin  seal. 

Culture-media. — The  food  substance  in  which  disease  germs 
will  grow  is  called  a  culture-medium.  The  natural  culture-media 
for  disease  germs  are  blood  and  the  tissues  of  the  body.  The 
principal  substances  which  are  used  in  making  artificial  culture- 
media  are  beef-broth,  gelatin,  sugar,  and  blood-serum.  Beef- 
broth  is  the  liquid  made  by  boiling  beef  in  water,  and  con- 
tains practically  all  the  various  kinds  of  substances  which  are 
found  in  flesh  itself.  Gelatin  is  often  added  to  it  in  order  to 
make  it  solid.  A  vegetable  gelatin  called  agar  is  commonly 
used. 

The  culture-medium  with  which  health  officers  have  the 
most  to  do  is  Loffler's  blood-serum,  on  which  diphtheria  germs 
are  grown.  This  is  a  solid  medium,  the  basis  of  which  is  the 
serum  of  blood  obtained  at  slaughter  houses.  Beef-broth  and 
sugar  are  mixed  with  it  to  form  a  medium  which  imitates  the 
tissues  of  the  body.  This  is  an  excellent  all-round  medium 
which  a  health  officer  can  use  for  obtaining  specimens  of  other 
disease  germs  besides  those  of  diphtheria. 

Every  culture-medium,  the  inside  of  its  container,  the  stopper, 
the  articles  used  in  taking  the  specimens,  and  everything  else 
that  may  touch  the  culture-medium,  must  be  entirely  free  from 
living  things  of  every  kind,  including  harmless  bacteria,  pro- 
tozoa, and  molds.  Rendering  an  article  free  from  every  form 
of  fife  is  called  sterilization,  and  is  usually  accomplished  by  means 
of  heat. 

A  temperature  of  at  least  140°  F.  (60°  C.)  is  needed  in  order 
to  kill  the  less  resistant  germs.  Some  spores  may  survive  a 
boiling  temperature,  and  so  the  heating  is  sometimes  done  with 
steam  under  about  15  pounds  pressure  in  order  to  obtain  a  tem- 
perature of  120°  C,  or  248°  F.  If  a  temperature  at  boiling  or 
above  will  injure  the  culture-medium,  a  method  of  fractional  or 
intermittent  sterilization  is  used.     This  consists  in  applying  heat 


134  THE   HEALTH    OFFICER 

for  half  an  hour  and  then  allowing  the  culture-media  to  stand 
for  a  day  at  the  temperature  of  the  body,  in  order  that  the  spores 
which  remain  ali\e  may  develop.  The  heat  is  then  applied 
again,  and  it  is  allowed  to  stand  as  before.  This  process  is 
repeated  on  three  or  four  successive  days  until  all  the  spores 
have  developed. 

Contamination  of  culture-tubes  and  flasks  by  air-borne  germs 
is  prevented  by  means  of  plugs  of  sterile  cotton  inserted  in  the 
necks  of  the  vessels. 

Some  bacteria  require  oxygen  for  their  growth,  and  will  not 
grow  if  the  air  is  excluded  from  the  culture.  These  are  called 
aerobes.  Others  will  not  grow  in  the  presence  of  air  and  oxygen. 
These  are  called  anaerobes.  When  a  culture  of  anaerobic  bac- 
teria is  to  be  grown,  the  culture-medium  may  be  protected  from 
air  by  a  coA'ering  of  oil. 

Obtaining  Specimens. — Disease  germs  to  be  planted  in  cul- 
ture-media are  obtained  from  the  surface  of  the  throat;  from 
sore  spots  on  the  skin;  from  the  discharges  and  excretions  of 
the  body;  from  specimens  of  flesh  removed  from  the  body;  from 
the  blood;  from  milk,  sewage,  or  other  liquids;  and  from  other 
materials  in  which  the  germs  are  suspected.  The  germs  are 
usually  obtained  and  introduced  into  culture-media  by  three 
methods:  1,  by  a  platinum  wire;  2,  by  a  pipet;  3,  by  a  sterile 
swab  of  absorbent  cotton. 

A  platinum  wire,  either  straight  or  bent  into  a  loop,  is  the 
ordinary  instrument  used  for  transplanting  bacteria.  Plati- 
num is  used  because  it  is  durable,  is  unaft'ected  by  chemicals, 
and  is  not  injured  by  heat.  There  are  four  steps  in  its  use: 
1,  It  is  heated  red  hot  in  the  flame  of  an  alcohol  lamp  or  Bunsen 
burner  in  order  to  destroy  all  life  on  it.  2,  It  is  dipped  into  a 
specimen  or  rubbed  over  the  surface  in  order  to  pick  up  the 
germs.  The  number  of  germs  that  may  adhere  to  the  end  of  the 
wire  may  be  millions.  3,  The  wire  is  dipped  into  a  liquid  cul- 
ture-medium or  is  rubbed  lightly  over  the  surface  of  a  solid 
one  in  order  to  plant  some  of  the  germs  in  the  medium.  4,  The 
wire  is  again  heated  red  hot  in  order  to  destroy  all  disease  germs 
that  may  be  left  on  it. 

Pipets  are  used  for  taking  up  measured  quantities  of  liquid. 
They  are  usually  made  of  glass.  The  larger  ones  are  graduated 
in  cubic  centimeters  and  the  smaller  ones  in  two  c.c.  They 
are  usually  furnished  with  sterile  rubber  tubes  which  are  used 
for  drawing  up  the  liquid  by  mouth  suction.  A  plug  of  cotton 
is  inserted  in  the  upper  end  of  the  tube  in  order  to  prevent  the 
entrance  of  the  liquid  into  the  mouth  if  too  much  suction  is 
accidentally  applied. 


BACTERIOLOGY  135 

Swabs  are  made  by  wrapping  bits  of  absorbent  cotton  around 
wires  or  splinters  of  wood,  enclosing  them  in  a  protective  case, 
and  sterilizing  them  with  heat.  One  is  removed  from  the  case 
and  rubbed  over  the  surface  on  which  the  germs  are  suspected, 
and  is  then  passed  lightly  over  the  surface  of  the  solid  culture- 
medium  in  order  to  transfer  some  of  the  germs  to  the  medium. 
The  swab  is  then  discarded  or  destroyed.  The  health  officers 
of  New  York  State  are  supplied  with  culture-tubes  and  swabs 
for  taking  specimens. 

Specimens  planted  in  a  culture-medium  are  placed  in  an 
incubator,  and  are  left  there  to  develop  for  a  few  hours  or  days. 
The  growth  in  a  liquid  medium  is  indicated  by  a  cloudiness; 
and  in  a  solid  medium,  by  a  discoloration  or  fuzziness  resembling 
a  spot  of  mold.  A  diphtheria  germ  may  become  two  germs  in  a 
half-hour,  and  at  that  rate  it  will  have  multiplied  to  280,000,000,- 
000,000  at  the  end  of  twenty-four  hours.  A  diphtheria  culture 
will  make  sufficient  growth  for  identification  in  from  twelve  to 
twenty-four  hours,  while  a  culture  of  tuberculosis  requires  from 
two  to  four  weeks. 

Cultures  are  examined  qualitatively  to  determine  the  species, 
and  quantitatively  to  determine  the  number  of  bacteria  that 
are  present  in  a  specimen.  When  germs  are  planted  in  a  soHd 
culture-medium,  each  individual  multiplies  and  produces  a 
colony  which  may  be  seen  with  the  naked  eye  or  with  the  low 
power  of  a  microscope.  The  appearance  of  the  colonies  is  char- 
acteristic for  each  species  of  bacterium,  and  by  it  alone  the 
species  may  often  be  determined. 

The  number  of  bacteria  in  a  specimen  is  determined  by  count- 
ing the  number  of  colonies  that  develop,  but  in  order  to  count 
them  the  quantity  of  the  specimen  must  be  known,  and  the 
colonies  must  be  separated  so  far  apart  that  they  may  be 
counted. 

A  standard  method  of  obtaining  a  culture  in  which  the  colo- 
nies are  so  few  that  they  will  be  separated  in  the  culture-medium 
is  to  take  a  measured  quantity  of  the  liquid  to  be  tested  and  di- 
lute it  with  a  known  amount  of  sterilized  water.  A  1  :  10  dilu- 
tion is  made  by  adding  1  c.c.  of  liquid  to  9  c.c.  of  water;  and  a 
1  :  100  dilution  by  adding  1  c.c.  of  dilution  No.  1  to  9  c.c.  of  water; 
and  a  1  :  1000  dilution  by  adding  1  c.c.  of  dilution  No.  2  to  9 
c.c.  of  water.  If  each  cubic  centimeter  of  the  original  liquid 
contained  10,000  bacteria,  each  cubic  centimeter  dilution  No.  3 
will  contain  10  bacteria,  and  if  it  is  planted  on  a  culture-medium, 
the  colonies  will  probably  be  widely  separated,  and  may  be 
readily  counted. 

A  pipet  graduated  in  tenths  and  hundredths  of  a  cubic 


136  THE  HEALTH   OFFICER 

centimeter  is  used  in  making  the  dilutions,  A  number  of  pipets 
are  sterilized  and  each  one  is  used  only  once,  and  is  then  washed 
and  sterilized  before  it  is  used  a  second  time. 

The  standard  method  of  making  a  culture  from  a  liquid  for 
a  quantitative  examination  is: 

1.  Liquefy  a  gelatin  culture-medium  with  heat.  The  me- 
dium will  remain  liquid  after  its  temperature  has  fallen  below  a 
point  at  which  the  disease  germs  will  not  be  injured. 

2.  Take  a  measured  quantity  of  the  liquid  to  be  tested  in  a 
sterilized  pipet. 

3.  Drop  the  liquid  into  the  liquefied  culture-medium. 

4.  Pour  the  mixture  into  a  Petri  dish  and  allow  it  to  solidify. 

5.  Incubate  it  in  an  incubator, 

6.  Count  the  colonies  that  develop. 

The  number  of  germs  in  a  liquid  that  is  examined  is  usually 
expressed  by  the  number  in  each  cubic  centimeter  of  the  sub- 
stance that  is  examined.  If  tfo  c.c.  of  a  substance  was  implanted 
on  a  culture-medium  and  20  colonies  developed,  the  number  of 
bacteria  per  cubic  centimeter  would  be  20  times  100  or  2000. 

Pure  Cultures. — A  specimen  containing  disease  germs  usually 
contains  other  kinds  of  bacteria,  and  possibly  protozoa,  many  of 
which  may  be  transferred  to  culture-media  and  may  grow  there 
along  with  the  disease  germs.  A  culture  in  Which  only  one 
species  of  germ  is  growing  is  called  a  pure  culture.  Disease  germs 
must  be  obtained  in  pure  cultures  in  order  that  accurate  tests 
and  determinations  may  be  made.  If  a  bacteriologist  has  a 
number  of  kinds  of  germs  growing  in  a  culture,  he  chooses  a 
group  or  colony  that  seems  to  be  composed  of  a  single  species, 
picks  up  a  bit  of  it  with  a  sterile  needle,  and  implants  it  in  a  sec- 
ond culture-medium.  He  repeats  the  process,  if  necessary,  with 
successive  cultures  until  he  obtains  a  pure  culture.  He  can 
then  grow  the  pure  cultures  in  any  quantity  that  he  pleases. 

Enrichment  of  Cultures. — A  bacteriologist  may  take  advan- 
tage of  a  slight  peculiarity  of  a  species  of  disease  germ  to  facilitate 
the  growth  of  that  species  while  restraining  the  growth  of  other 
kinds.  This  increase  in  the  proportion  of  a  particular  species 
of  bacteria  is  called  an  enrichment  of  its  culture.  Two  examples 
of  enrichment  methods  are  those  employed  in  the  recognition  of 
t>phoid  fever  bacilli  and  of  diphtheria  bacilli. 

T^-phoid  fever  germs  in  the  intestinal  excrettans  are  associ- 
ated with  colon  bacilli.  A  slight  trace  of  the  dye  called  brilliant 
green,  added  to  a  culture-medium,  restrains  the  growth  of  colon 
bacilli,  but  has  little  or  no  effect  on  the  typhoid  bacilli.  If  a 
specimen  containing  a  few  typhoid  germs  and  many  colon  bacilli 
is  inoculated  into  the  dyed  medium,  the  typhoid  germs  will 


BACTERIOLOGY  137 

outgrow  the  colon  bacilli,  and  may  be  obtained  in  nearly  pure 
cultures. 

A  specimen  from  a  diphtheritic  throat  contains  diphtheria 
germs  mixed  with  many  others.  Loffler's  blood-serum  medium 
is  peculiarly  well  fitted  for  growing  diphtheria  bacilli,  and  when 
a  mixed  specimen  of  diphtheria  and  other  germs  are  planted  on 
it,  the  diphtheria  germs  usually  outgrow  the  others,  and  form 
an  almost  pure  culture;  but  after  a  few  hours  the  other  germs 
may  catch  up  with  the  diphtheria  germs  and  mingle  with  them 
in  an  indistinguishable  mass. 

Recognition  of  Bacteria. — A  diagnosis  of  the  species  of  dis- 
ease germ  that  is  present  in  a  culture  is  made:  1,  by  the  appear- 
ance of  the  colonies  in  the  culture-media;  2,  by  the  microscopic 
appearance  of  the  individual  germs;  3,  by  the  products  resulting 
from  their  growth;  4,  by  the  results  of  inoculating  animals  with 
the  disease  germs;  5,  by  testing  the  germs  with  serums. 

Appearance  of  Colonies. — The  appearance  of  the  colonies  in 
pure  cultures  and  the  manner  of  their  growth  are  characteristic 
for  each  species  of  disease  germ,  and  by  observing  them  a  bac- 
teriologist is  often  able  to  identify  a  micro-organism. 

Staining. — Individual  disease  germs  are  naturally  almost 
colorless,  transparent,  and  invisible.  When  a  specimen  is  pre- 
pared for  examination  with  a  microscope,  the  germs  are  generally 
colored  with  stains  or  dyes  to  make  them  visible.  Various  dis- 
ease germs  and  various  parts  of  the  same  germ  differ  in  their 
staining  qualities,  and  these  differences,  together  with  the  forms 
of  the  germs,  make  their  recognition  possible.  The  common 
stains  are  analine  dyes. 

The  method  of  preparing  a  stained  specimen  from  a  culture 
for  examination  with  a  microscope  is  as  follows: 

1.  Pick  up  a  small  quantity  of  germs  from  a  colony  with  a 
platinum  wire. 

2.  Smear  the  germs  in  a  thin  layer  upon  a  microscope  slide. 

3.  Fix,  or  coagulate,  the  smear  with  heat  or  by  immersion  in 
alcohol. 

4.  Apply  the  stain. 

5.  Wash  and  dry  the  slide. 

Bacterial  Products. — Some  bacteria  may  be  recognized  by  the 
products  which  are  formed  by  their  growth.  Bacteriologic 
examinations  of  water  and  sewage  are  made  principally  for  the 
detection  of  colon  bacilh,  or  common  intestinal  bacteria,  which 
are  recognized  by  their  production  of  acids  and  gases  when 
they  are  grown  in  media  containing  sugar. 

The  test  for  the  production  of  acid  is  made  with  a  neutral 
or  faintly  alkaline  medium  of  agar  and  lactose  containing  a  trace 


138  THE   HEALTH    OFFICER 

of  phenolphthalein  as  an  indicator  of  acidity,  for  it  is  red  in  an 
alkaline  medium  and  colorless  in  an  acid  one.  This  medium  is 
mixed  with  a  specimen  to  be  tested  and  is  poured  into  a  Petri 
dish.  Each  colony  of  acid-producing  bacilli  forms  a  colorless 
spot  in  a  held  of  unchanged  red  agar. 

The  test  for  the  production  of  gases  is  made  by  inoculating 
lactose  broth  with  the  specimen,  and  placing  it  in  a  double  tube, 
one  part  of  which  has  a  closed  end.  If  gas  is  produced,  it  col- 
lects in  the  closed  part  of  the  tube.  This  is  called  a  fermentation 
test.  If  both  the  acid  and  the  fermentation  tests  are  positive, 
the  specimen  may  be  considered  to  contain  colon  baciUi. 

The  species  to  which  bacteria  belong  may  often  be  recog- 
nized by  their  abihty  to  produce  fermentation  in  various  kinds 
of  sugar,  such  as  dextrose,  lactose,  saccharose,  dulcite,  and  man- 
nite.  Sugar  fermentation  tests  are  often  used  to  identify  the 
various  kinds  of  colon  bacilli  and  of  streptococci. 

Tests  of  Animal  Inoculations. — When  disease  germs  are  in- 
troduced, or  inoculated,  into  a  susceptible  person  or  animal, 
they  may  grow  and  multiply  and  produce  the  disease  in  that 
person  or  animal.  The  following  four  conditions  must  be  met 
in  order  to  prove  that  a  particular  organism  is  the  cause  of  a 
disease: 

1.  The  particular  organisms  shall  be  found  in  the  diseased 
part  of  the  body  of  the  person  or  animal  having  the  disease. 

2.  The  organisms  taken  from  the  sick  person  or  animal  shall 
be  grown  in  a  succession  of  pure  cultures  until  they  are  entirely 
free  from  every  particle  of  matter  from  their  original  source. 

3.  The  inoculation  of  the  pure  culture  into  a  susceptible 
person  or  animal  shall  produce  the  disease. 

4.  The  germs  shall  be  found  in  the  diseased  parts  of  the 
inoculated  animal. 

The  statements  of  these  four  conditions  are  known  as  Koch's 
postulates. 

The  diagnosis  of  some  diseases  may  be  made  with  certainty 
by  inoculating  some  of  the  cultures  from  a  susceptible  person 
into  a  lower  animal.  The  specimens  taken  from  a  human  being 
may  contain  several  kinds  of  organisms,  but  the  only  ones  that 
grow  are  those  which  are  particularly  well  adapted  to  growing 
in  the  inoculated  animal.  The  growth  of  the  germs  in  an  animal 
is  similar  to  that  of  wheat  sowed  as  seed.  Many  kinds  of  weed 
seeds  also  are  emplanted  in  the  soil,  but  only  the  wheat  grows 
and  produces  an  uncontaminated  crop.  A  guinea-pig  is  espe- 
cially susceptible  to  the  germs  of  tuberculosis,  and  if  a  specimen 
containing  the  germs  is  injected  into  the  animal,  the  pig  will 
almost  surely  develop  tuberculosis.     The  diagnosis  of  rabies  is 


BACTERIOLOGY  139 

often  made  by  the  inoculation  of  suspected  material  into  rab- 
bits; and  of  pneumonia  by  inoculation  of  the  sputum  into  white 
mice. 

Serum  Tests. — The  blood-serum  of  a  person  who  has  a  com- 
municable disease  has  definite  effects  on  pure  cultures  of  the 
organisms  of  that  disease.  These  effects  will  be  described  in 
the  chapter  on  Immunity. 

Molds  are  microscopic  plants  which  consist  of  elongated 
cells  joined  end  to  end,  called  mycelium.  The  plants  multiply 
in  three  ways:  1,  by  division  of  the  cells;  2,  by  the  branching 
of  the  cells,  and  3,  by  the  formation  of  spores.  The  fuzzy  growth 
which  we  call  mold  on  bread  consists  of  the  spore  cases  of  molds. 
The  spores  float  everywhere  in  the  air,  and  are  ready  to  grow 
whenever  they  fall  upon  the  proper  food  substances. 

Molds  cause  decay  and  decomposition  on  the  substances  on 
which  they  grow.  Ringworm  and  sporotrichosis  are  diseases 
which  are  caused  by  molds  growing  on  the  human  skin. 

Yeasts  are  oval  plants  each  of  which  consists  of  a  single 
cell.  They  multiply  by  means  of  buds  which  are  put  forth  on 
the  sides  of  the  parent  cells.  Yeast  plants  become  dry  and 
float  in  the  air,  and  are  ready  to  grow  when  they  fall  upon  the 
proper  food  substances.  They  cause  fermentation  in  sugary 
solutions  and  change  the  sugar  to  alcohol  and  carbon  dioxid. 

Yeasts  and  molds  are  of  special  interest  to  the  health  officer 
because  of  their  relation  to  the  preparation  and  preservation  of 
food. 


CIL\PTER  XIV 

IMMUNITY 

Every  living  thing  has  the  power  of  resisting  and  over- 
coming the  common  bacteria,  molds,  and  other  micro-organisms 
that  assail  it;  but  when  life  ceases,  its  substance  is  soon  destroyed 
by  these  same  organisms.  There  are  many  kinds  of  micro- 
organisms, but  only  a  few  are  able  to  grow  in  the  living  human 
body.  Those  which  concern  a  health  officer  number  only  two 
or  three  dozen.  The  ability  of  the  Hvmg  body  to  resist  micro- 
organisms or  their  products  is  called  immunity. 

Very  few  communicable  diseases  are  always  fatal,  but  the 
body  is  usually  able  to  overcome  the  organisms  that  invade  it, 
and  to  e.xpel  them,  and  to  repair  the  damage  which  they  have 
done.  We  say  that  the  body  of  a  person  who  has  defensive 
forces  ready  to  repel  an  invading  organism  is  immune  to  the 
disease  that  would  be  produced  by  that  organism.  The  body 
may  be  unprepared  to  resist  micro-organisms  at  the  time  of  their 
invasion,  and  yet  after  a  time  it  may  be  able  to  collect  its  forces 
and  manufacture  the  munitions  with  which  it  finally  expels  the 
invaders.  Those  who  die  from  a  communicable  disease  were 
unprepared  for  resisting  the  organisms,  and  were  unable  to 
muster  sufficient  forces  to  overcome  the  microscopic  foes. 

Phagocytosis. — A  considerable  degree  of  resistance  to  disease 
germs  exists  in  every  cell  in  the  body;  but  it  exists  to  a  very  great 
degree  in  the  white  blood-cells,  or  leukocytes.  One  of  the  spe- 
cial duties  of  leukocytes  is  to  envelop  and  destroy  bacteria  and 
other  micro-organisms  that  enter  the  body.  They  visit  every 
part  of  the  body  with  the  blood.  They  have  the  power  of  chang- 
ing their  shapes  and  of  moving  independently  of  the  other  cells 
and  fluids  of  the  body.  They  can  pass  through  the  walls  of  the 
capillaries  and  enter  the  intercellular  spaces  with  the  lymph. 
They  are  attracted  by  any  substance  which  does  not  normally 
belong  among  the  cells  of  the  body,  and  especially  by  clumps 
of  bacteria  in  the  tissues.  They  collect  in  great  numbers  around 
disease  germs  that  enter  the  flesh.  A  white  blood-cell,  meeting 
a  bacterium,  envelops  it  and  proceeds  to  dissolve  it  by  a  process 
of  digestion  which  is  similar  to  the  action  of  the  pepsin  ferment 
pi  the  stomach  on  food.  The  action  of  white  blood-cells  on  bac- 
teria may  have  originally  been  one  of  nourishment,  which,  in 
the  course  of  ages  of  evolution,  has  developed  into  a  means  of 
140 


IMMUNITY  ^  141 

defense  for  the  body.  The  process  is  called  phagocytosis,  and 
the  white  blood-cells  themselves  are  often  called  phagocytes, 
meaning  eating  cells. 

Regeneration  in  Excess. — If  bacteria  are  extremely  poison- 
ous, they  may  kill  numbers  of  the  phagocytes;  but  an  excess 
of  the  protective  cells  develops  and  reinforces  those  in  the 
danger  zone  until  their  number  in  the  blood  may  be  several 
times  the  normal.  A  count  of  the  number  of  white  cells  in  the 
blood  is  often  made  in  order  to  determine  the  probable  presence 
of  infectious  organisms  in  the  body,  and  to  form  an  estimate  of 
its  defensive  powers. 

Regeneration  in  excess  of  immediate  needs  after  an  injury  or 
unusual  action  is  a  principle  which  lies  at  the  basis  of  the  ex- 
planation of  many  familiar  processes  in  the  body.  For  example, 
a  muscle  increases  in  size  after  exercise;  and  a  broken  bone 
produces  an  excess  of  callus  during  the  reparative  process. 
This  is  also  a  basic  principle  in  the  explanation  of  nearly  all  the 
processes  in  producing  immunity. 

Action  of  Blood-serum  on  Bacteria. — The  phagocytes  and 
other  cells  give  off  a  portion  of  their  digestive  substances,  or 
enzymes,  and  so  the  blood-serum  itself  has  a  dissolving  or  digest- 
ive action  on  bacteria.  This  process  is  called  the  bactericidal 
(bacteria  killing)  property  of  the  serum.  The  action  is  a  chem- 
ical one  upon  the  substance  of  the  invading  organism,  and  is  the 
same  whether  the  organism  is  alive,  or  dead,  or  is  crushed  to 
pieces.  It  is  an  action  upon  the  protein  of  the  organism  and 
takes  place  upon  any  protein  that  is  strange,  ox  foreign,  to  the 
tissues  or  blood.  A  foreign  protein  is  one  whose  composition 
differs  from  the  composition  of  the  natural  proteins  of  the  tissues 
of  the  animal  into  which  it  is  injected.  An  example  of  a  foreign 
protein  is  horse-serum  when  it  is  injected  into  a  human  being. 

Parenteral  Products  of  Digestion.^Most  food  proteins  are 
not  poisonous  in  themselves,  but  they  may  become  poisonous 
after  they  have  been  acted  upon,  or  digested,  by  any  ferment  or 
enzyme  including  that  which  ordinarily  exists  in  the  blood. 
The  digestive  action  which  takes  place  in  the  blood  or  tissues 
is  called  parenteral  digestion,  or  digestion  outside  of  the  intes- 
tine. The  crude  products  of  any  digestion  of  protein  are  poison- 
ous to  the  body  until  they  have  been  subjected  to  a  further 
action  by  the  living  cells  or  their  enzymes,  and  have  become 
changed  to  the  forms  of  protein  which  are  naturally  found  in 
the  blood  and  tissues.  For  example,  the  peptone  produced  by 
intestinal  digestion  is  poisonous,  but  the  cells  which  Hne  the 
intestine  have  a  special  power  of  changing  it  to  the  harmless 
and  useful  forms  in  which  protein  exists  in  the  blood. 


142  THE   HEALTH    OFFICER 

The  enzymes  that  are  naturally  found  in  the  blood  are  usu- 
ally small  in  quantity.  If  a  foreign  protein  is  injected  into  the 
bod}-,  the  enzNines  may  digest  it  so  slowly  that  no  poisoning 
effects  of  the  products  may  be  apparent.  But  the  principle  of 
regeneration  to  excess  here  comes  into  operation.  The  presence 
of  a  foreign  protein  in  the  blood  may  stimulate  the  body  cells 
to  produce  an  excess  of  enz\-mes.  If  now  the  same  foreign  pro- 
tein is  injected  a  second  time,  the  enzymes  that  were  produced 
by  the  first  injection  may  be  sufficient  in  quantity  to  act  at  once 
and  to  produce  a  dangerous  quantity  of  poisonous  products. 
Making  the  body  sensitive  to  the  poisonous  effects  of  a  protein 
is  called  soisitizcition.  A  foreign  protein  which  is  used  to  pro- 
duce sensitization  is  called  an  antigen. 

Specific  Sensitization. — There  are  many  forms  of  protein  and 
each  fomi  requires  a  special,  or  specific,  enzyme  for  its  digestion. 
For  example,  the  injection  of  the  white  of  a  hen's  egg  into  a 
guinea-pig  sensitizes  the  pig  to  the  egg  by  stimulating  the  body 
cells  to  produce  the  enz}Tiie  that  digests  the  white  of  egg  and  no 
other  form  of  protein.  If  a  second  dose  of  white  of  egg  is  given 
about  two  weeks  after  the  first  one,  the  animal  will  be  poisoned 
quickly;  but  if  horse-serum  is  given,  there  will  be  no  effects,  for 
the  enzyme  which  digests  white  of  egg  will  not  digest  the  protein 
of  horse-serum.  Sensitization,  therefore,  is  not  general  and 
does  not  affect  all  proteins,  but  it  is  specific  and  applies  only  to 
the  particular  one  by  which  the  sensitization  was  produced. 

Anaphylaxis. — An  increased  susceptibility  to  poisoning  fol- 
lowing sensitization  with  a  protein  is  called  anapliylaxis.  An 
example  of  anaphylaxis  is  the  itching  and  redness  which  appears 
in  a  \accinated  spot  within  two  or  three  days  in  a  person  who 
had  been  vaccinated  a  short  time  previously.  The  defensive 
substances  produced  by  the  first  vaccination  attack  and  destroy 
the  germs  of  the  second  vaccination  within  a  short  time  after 
they  have  been  introduced,  and  the  large  quantity  of  poisons 
suddenly  liberated  produces  the  redness  and  itching. 

Other  examples  of  anaphylaxis  are  the  sensitiveness  to  pollen 
in  a  person  who  is  subject  to  hay-fever,  and  the  skin  eruptions 
which  sometimes  occur  after  eating  certain  foods,  such  as  straw- 
berries or  shellfish. 

Anaphylaxis  is  of  special  interest  to  a  health  officer  in  its 
relation  to  the  serum  sickness  that  sometimes  follows  the  injec- 
tion of  antitoxin.  The  symptoms  are  due  to  the  fact  that  horse- 
serum,  in  which  antitoxin  is  contained,  is  a  foreign  protein  to 
man.  There  are  two  forms  of  serum  sickness.  The  common 
form  is  a  red  and  itching  skin  eruption  that  begins  about  a  week 
after  the  antitoxin  has  been  given.     It  is  harmless  and  lasts  for 


IMMUNITY  143 

only  a  few  days.  It  is  now  becoming  rare,  for  manufacturers 
remove  a  large  proportion  of  the  proteins  from  the  serum. 

The  other  form  of  serum  sickness  is  a  collapse  that  comes 
on  with  great  suddenness  a  moment  after  the  horse-serum  is 
given.  It  is  extremely  rare  except  in  those  persons  who  have 
what  is  called  horse  asthma.  This  asthma  resembles  the  asthma 
of  hay-fever,  and  is  produced  by  the  inhalation  of  particles  that 
are  given  off  by  horses.  If  antitoxin  must  be  given  to  a  per- 
son who  is  subject  to  asthma,  inject  2  or  3  drops  and  wait  two 
hours.  If  no  unpleasant  signs  appear,  the  rest  of  the  antitoxin 
may  be  given  with  safety. 

A  person  who  has  recovered  from  an  infectious  disease  is 
sensitized  to  the  germs  of  that  disease  and  may  be  in  the  state 
of  the  guinea-pig  that  has  been  sensitized  with  white  of  egg. 
If  germs  of  that  disease  should  invade  his  body  again,  their 
effects  would  depend  on  their  quantity.  If  an  ordinary  infec- 
tion should  occur,  the  quantity  of  germs  that  would  enter  the 
body  would  be  microscopic  and  so  small  in  amount  that  their 
destruction  would  produce  no  apparent  effects.  If  a  large 
quantity  of  germs  should  be  introduced  artificially,  their  sudden 
destruction  and  digestion  would  probably  Hberate  an  amount  of 
poison  that  might  produce  sickness  and  death.  Thus  the  means 
which  produce  immunity  to  a  disease  may  be  a  source  of  danger 
when  the  poisons  of  that  disease  are  introduced  into  the  body 
in  excessive  amounts,  as  is  often  done  in  animal  experimentation. ' 

Development  of  an  Infectious  Disease. — The  germs  of  an 
infectious  disease  act  like  a  foreign  protein.  If  the  bacteria  of 
a  disease  enter  the  body  of  a  person  whose  blood  has  no  enz^Tnes 
for  defense  against  that  particular  form  of  germ,  the  bacteria 
may  grow  and  multiply;  but  they  produce  no  sickness  for  some 
days,  for  at  first  there  is  no  digestion  or  destruction  of  the  bac- 
terial proteins.  But  the  presence  of  the  proteins  stimulates  the 
body  cells  to  prepare  the  enzymes  which  will  digest  the  foreign 
substances;  and  signs  of  poisoning  and  of  sickness  appear  as 
soon  as  the  active  destruction  and  digestion  of  the  bacteria 
begin.  When  all  the  bacteria  have  been  destroyed,  and  the 
products  of  their  digestion  have  been  thrown  o£f  from  the  body, 
the  disease  is  at  an  end. 

Immunity. — After  a  person  has  recovered  from  an  infectious 
disease,  the  protective  enzymes  often  remain  in  his  blood,  and 
are  ready  to  destroy  the  germs  of  that  disease  which  may  after- 
ward enter  the  body.  A  person  who  has  had  an  infectious  dis- 
ease is,  therefore,  immune  to  it  as  long  as  the  defensive  substances 
remain  in  his  body.  The  immunity  may  last  a  lifetime,  as  after 
smallpox,  scarlet  fever,  and  measles;  or  it  may  be  brief,  as  after 


144  THE  HEALTH   OFFICER 

pneumonia  and  diphtheria.  The  defensive  substances  may  not 
remain  in  the  body  at  all.  or  there  may  even  be  an  increased 
susceptibility  after  one  attack  of  a  disease,  such  as  malaria,  for 
example. 

The  opposite  condition  to  immunity  to  a  disease  is  called 
susceptibility.  This  condition  exists  when  the  defensive  sub- 
stances are  insufficient  in  quantity  or  quality  to  destroy  the 
disease  germs  when  they  enter  the  body. 

Toxins.— A  poison  which  is  produced  by  disease  germs  is 
usually  called  a  toxin;  but  the  word  toxin  is  strictly  applied  to 
a  poison  which  is  given  off  by  bacteria;  while  the  word  endo- 
toxin is  applied  to  a  poison  that  is  retained  in  the  bodies  of 
bacteria.  There  are  very  few  true  toxins.  The  toxins  with 
which  a  health  officer,  is^ chiefly  concerned  are  those  of  diph- 
theria and  tetanus.^-'''^Tne  bacteria  of  diphtheria  and  tetanus  are 
only  slightly  poisofious,  but  if  the  toxin  of  either  of  these  dis- 
eases is  injected  into  the  body,  it  produces  the  signs  and  symp- 
toms of  the  disease. 

A  toxin  has  the  characteristics  of  a  protein  substance,  but  no 
toxin  has  been  isolated  in  pure  form.  What  is  called  diphtheria 
toxin  is  the  broth  in  which  diphtheria  bacilli  have  grown.  Toxins 
are  intensely  poisonous  and  yet  they  do  not  begin  to  aft'ect  the 
body  until  some  hours  or  days  after  they  have  entered  it. 

Antibodies. — The  substances  which  protect  the  body  against 
the  germs  of  infectious  diseases  and  other  foreign  proteins  are 
called  antibodies.  Three  kinds  of  antibodies  in  which  a  health 
officer  is  especially  interested  are  antitoxins,  agglutinins,  and 
lysins. 

Antitoxins. — When  a  toxin  is  injected  into  the  tissues,  it 
causes  the  cells  to  produce  an  antibody  called  an  antitoxin. 
The  composition  of  antitoxins  is  unknown.  The  eft'ect  of  an 
antitoxin  is  to  combine  with  its  toxin,  if  any  is  present  in  the 
body,  and  render  it  inert.  The  principal  factor  in  bringing  about 
recovery  in  diphtheria  or  tetanus  is  the  antitoxin  which  is  pro- 
duced in  the  body.  There  is  also  a  production  of  substances 
which  kill  and  destroy  the  bacteria  themselves,  as  in  other 
diseases.  The  antitoxins  for  diphtheria  and  for  tetanus  may 
be  produced  in  animals  and  be  used  for  the  prevention  and  cure 
of  the  diseases  in  mankind. 

Manufacture  of  Antitoxin. — When  an  animal  receives  an  in- 
jection of  toxin,  it  produces  an  antitoxin  in  excess  of  that  re- 
quired to  neutralize  the  toxin.  When  the  injection  is  repeated 
several  times,  increasing  quantities  of  antitoxin  are  produced, 
and  are  contained  in  the  blood.  A  horse  is  generally  used  for 
producing  antitoxin  because  it  forms  a  large  quantity  in  pro- 


IMMUNITY  145 

portion  to  its  size,  and  also  because  the  effect  of  its  serum  is 
seldom  harmful  to  man. 

A  standard  method  of  manufacturing  diphtheria  antitoxin  is  i^ 
as  follows:  A  horse  is  given  an  injection  of  \  drop  of  diphtheria 
toxin,  which  is  about  all  that  an  untreated  horse  can  endure. 
The  injection  is  repeated  with  increasing  doses  of  toxin  every 
third  day,  until  about  1  pint  of  the  toxin  is  given  at  the  end  of 
about  two  months,  and  the  blood  contains  its  maximum  amount 
of  antitoxin.  About  3  gallons  of  blood  are  then  drawn  from  the 
horse  and  allowed  to  clot.  The  serum  is  taken  and  sufficient 
ammonium  sulphate  is  added  to  make  a  solution  that  is  30  per 
cent,  of  saturation.  A  precipitate  falls,  which  is  discarded. 
More  ammonium  sulphate  is  added  up  to  50  per  cent,  of  satura- 
tion. The  precipitate  which  then  forms  contains  the  antitoxin. 
This  precipitate  is  pressed  free  from  the  excess  of  liquid  and  is 
placed  in  a  bag  of  parchment  paper  and  suspended  in  running 
water  to  dialyze  for  several  days.  The  ammonium  sulphate 
passes  into  the  water,  and  the  water  enters  the  bag  and  dissolves 
the  precipitate.  The  solution  is  the  concentrated  and  purified 
antitoxin  which  is  used  in  human  beings. 

Antitoxin  is  tested  in  the  following  manner:  Minute  quanti- 
ties of  toxin  are  injected  into  a  series  of  guinea-pigs  in  order  to 
determine  its  smallest  fatal  dose,  which  is  ordinarily  about 
Tz  drop  of  a  pure  culture.  A  series  of  minimum  fatal  doses  of 
toxin,  prepared  by  mixing  them  with  variable  quantities  of 
antitoxin,  is  then  injected  into  another  series  of  guinea-pigs  in 
order  to  determine  the  smallest  quantity  of  the  antitoxin  that 
will  exactly  neutralize  one  fatal  dose  of  toxin.  The  quantity 
of  diphtheria  antitoxin  which  will  exactly  neutralize  100  times 
the  quantity  of  toxin  that  is  fatal  for  one  guinea-pig  is  called  a 
unit  of  diphtheria  antitoxin. 

Tetanus  antitoxin  is  produced  in  the  same  manner  as  diph- 
theria antitoxin,  but  the  tetanus  antitoxin  unit  will  neutralize 
1000  times  the  quantity  of  tetanus  toxin  that  would  kill  a 
guinea-pig. 

Agglutinins. — Some  bacterial  antigens  give  rise  to  antibodies 
whose  effect  is  to  cause  the  bacteria  to  cease  their  movements 
and  to  collect  in  clumps.  These  antibodies  are  called  agglutinins. 
An  agglutinin  in  the  blood  does  not  kill  bacteria,  but  it  may  have 
some  effect  in  causing  them  to  collect  in  clumps  which  renders 
them  susceptible  to  the  attacks  of  the  phagocytes. 

Agglutination  is  a  specific  action  and  affects  only  the  bac- 
teria which  are  of  the  same  kind  as  those  which  caused  the 
development  of  the  agglutinin  in  the  blood.  For  example,  the 
agglutinin  produced  by  typhoid  germs  in  the  body  acts  on  ty- 


146  THE   HEALTH    OFFICER 

phoid  fever  germs  and  not  on  the  germs  of  pneumonia,  or  diph- 
theria, or  those  of  other  diseases.  It  is  also  quantitative,  and 
a  given  quantity  of  serum  will  agglutinate  a  given  quantity  of 
bacteria.  The  test  is  usually  made  with  scrum  diluted  with 
normal  salt  solution,  and  the  strength  of  agglutination  is  ex- 
pressed by  the  degree  of  dilution  at  which  a  scrum  will  act;  as, 
for  example,  in  a  1  :  10  or  1  :  1000  dilution. 

A  practical  application  of  agglutination  is  made  in  the  diag- 
nosis of  a  disease  by  testing  the  blood-serum  of  the  suspected 
patient  with  known  bacteria.  For  example,  the  test  for  typhoid 
fever  is  made  by  taking  a  drop  of  blood  from  the  suspected 
person  and  observing  its  agglutinating  power  upon  a  pure  cul- 
ture of  typhoid  bacilli.  If  typhoid  fever  is  present,  the  blood 
will  agglutinate  the  typhoid  bacilli. 

A  serum  which  contains  a  known  agglutinin  may  be  used  to 
identify  an  unknown  variety  of  bacteria.  If  a  guinea-pig  or 
rabbit  is  injected  with  a  pure  culture  of  bacteria,  its  blood-serum 
will  contain  an  agglutinin  which  will  act  on  that  variety  of  bac- 
teria, and  only  slightly  or  not  at  all  on  other  kinds.  One  prac- 
tical application  of  the  test  is  made  in  the  diagnosis  of  pneimionia. 
A  number  of  kinds  of  pneumococci  may  produce  the  disease. 
The  pneumococci  may  be  recovered  from  the  sputum  and  sub- 
jected to  agglutination  tests  with  the  serum  of  animals  that 
have  been  injected  with  known  varieties  of  pneumococci.  The 
variety  present  is  indicated  by  the  serum  with  which  agglutina- 
tion is  produced. 

Laboratories  keep  a  supply  of  animals  that  have  been  in- 
jected with  known  bacteria,  and  whose  serums  have  been  tested 
for  their  agglutinating  powers. 

Methods  of  Testing  Agglutination. — When  a  considerable 
quantity  of  serum  and  bacteria  is  mixed  in  a  test-tube,  the  ag- 
glutinated bacteria  are  visible  with  the  naked  eye,  and  appear 
as  a  white  flocculent  precipitate.  When  a  test  is  made  by  this 
method,  a  series  of  tubes  is  set  up  each  containing  0.1  c.c.  of 
bacteria  in  suspension.  Then  to  each  tube  except  the  last  there 
is  added  0.9  c.c.  of  a  series  of  dilutions,  1  :  10,  1  :  50,  etc.,  of  the 
serum  in  normal  salt  solution.  The  salt  solution  only  is  added 
to  the  bacteria  in  the  last  test-tube  as  a  control  test.  The  tubes 
are  placed  in  an  incubator,  and  after  about  an  hour  they  are 
removed  to  an  ice-box  to  allow  the  precipitate  to  settle.  The 
liquid  in  the  tubes  in  which  complete  agglutination  has  taken 
place  will  be  clear,  while  the  other  tubes  will  be  cloudy  from  the 
bacteria  which  remain  in  suspension.  The  strength  of  the 
agglutination  is  indicated  by  the  greatest  dilution  at  which  a 
complete  clearing  of  the  liquid  takes  place.     The  test  may  also 


IMMUNITY  147 

be  done  upon  bacteria  which  have  been  dissolved  or  disinte- 
grated.    It  is  often  called  a  precipitin  test. 

Another  method  of  doing  an  agglutination  test  is  to  observe 
the  clumping  of  bacteria  in  a  hanging-drop  under  a  microscope. 
A  test  requires  the  use  of  a  microscope  slide  on  which  a  deep 
hollow  I  inch  in  diameter  is  ground.  The  glass  around  the 
hollow  is  smeared  with  vaselin  to  prevent  the  evaporation  of 
the  specimen.  The  serum  and  bacteria  are  mixed,  and  a  drop 
is  placed  on  a  cover-glass,  which  is  then  inverted  over  the  center 
of  the  hollow.  The  drop  is  examined  with  a  |-inch  objective. 
Bacteria  at  first  will  be  uniformly  scattered  over  the  field  of  view, 
but  if  agglutination  takes  place,  they  will  soon  collect  in  clumps 
of  twenty-five  or  more.  The  degree  of  agglutination  is  measured 
by  the  greatest  dilution  at  which  the  clumping  takes  place. 

The  Widal  Reaction.- — The  principal  agglutination  test  in 
which  a  health  officer  is  interested  is  that  for  typhoid  fever. 
The  germs  of  typhoid  fever  growing  in  the  body,  or  injected  into 
it,  act  as  an  antigen  and  produce  an  agglutinin  which  has  a 
strong  action  upon  typhoid  fever  germs,  and  only  a  slight  ac- 
tion, or  none,  on  other  kinds  of  germs.  In  order  to  perform  the 
test  take  some  blood-serum  from  a  person  who  is  suspected  of 
having  typhoid  fever  and  mix  it  in  varying  dilutions  with  a 
pure  culture  of  typhoid  bacilli.  The  test  is  usually  made  by  the 
microscopic  method.  A  clumping  of  the  bacilli  indicates  the 
presence  of  typhoid  agglutinins.  This  test  is  called  the  Widal 
reaction.  The  test  is  considered  positive  if  it  takes  place  with 
a  serum  dilution  of  1  :  40  or  greater  within  thirty  minutes. 

Group  Agglutination. — The  reaction  of  agglutination  is  caused 
by  the  proteins  of  bacteria.  A  group  of  closely  related  bacteria 
may  have  a  certain  kind  of  protein  in  common.  The  serum  of 
a  person  or  animal  that  has  been  injected  with  bacteria  belong- 
ing to  any  species  of  the  group  will  agglutinate  the  bacteria  of 
all  the  species;  and  the  strength  of  the  agglutination  will  be  in 
proportion  to  the  amount  of  the  common  protein  in  the  bacteria 
that  are  tested.  For  example,  the  typhoid,  paratyphoid,  dysen- 
tery, and  colon  bacilli  form  a  group.  An  individual  bacterium 
of  each  group  is  composed  principally  of  its  own  particular  kind 
of  protein,  but  it  also  contains  a  small  quantity  of  the  particular 
protein  of  each  of  the  other  bacteria  in  the  group.  If  a  typhoid 
serum  will  agglutinate  typhoid  bacilli  in  a  high  dilution,  say 
1  :  200,  it  may  also  agglutinate  colon  bacilli  in  a  low  dilution, 
say  1  :  10. 

Group  agglutinations  must  be  considered  in  the  interpreta- 
tion of  a  report  of  a  Widal  reaction.  A  positive  reaction  with  a 
dilution  of  1  :  20  might  mean  an  infection  with  parat}^hoid  or 


148  THE  HEALTH   OFFICER 

colon  bacilli,  but  a  prompt  reaction  with  a  dilution  of  1  :  40  is 
proof  of  infection  with  tx-phoid  bacilli. 

Lysis. — The  digestive  action  of  blood-serum  on  foreign  pro- 
tein is  called  lysjs,  and  the  substances  which  perform  the  diges- 
tion are  called  lysins.  The  action  of  a  lysin  is  similar  to  that  of 
the  gastric  juice.  It  will  take  place  upon  any  mass  of  foreign 
protein,  or  upon  bacteria,  or  upon  red  blood-cells  of  an  animal 
of  a  species  different  from  that  of  the  one  supplying  the  serum. 
The  destructive  action  upon  red  blood  cells  of  the  foreign  species 
is  called  hemolysis;  and  that  upon  bacteria  is  called  bacterio- 
lysis. This  action  is  largely  obscure,  but  one  phase  has  been 
traced  and  applied  in  what  is  known  as  the  complement-fixation 
test. 

A  great  difficulty  in  reading  literature  relating  to  lysins  is 
the  confusion  of  terms  and  expressions.  The  following  defini- 
tions will  aid  in  understanding  the  subject: 

Foreign  Protein. — A  protein  whose  composition  differs  from 
that  of  the  protein  of  the  person  or  animal  into  which  it  is 
injected.  Horse-serum  is  a  foreign  protein  to  man;  and  red 
blood-cells  of  a  sheep  are  to  a  rabbit. 

Sensitize. — To  make  the  body  sensitive  to  the  poisonous 
effects  of  a  protein,  or  to  cause  the  body  to  produce  substances 
which  will  destroy  a  particular  protein  that  is  introduced  into 
the  body  (see  p.  142). 

Antibody. — A  substance  which  protects  a  body  against  germs 
of  infectious  diseases  or  other  foreign  protein. 

Lysin. — An  antibody  which  will  destroy  a  foreign  protein. 

Antigen.^A  foreign  protein,  such  as  bacteria  or  red  blood- 
cells,  which  will  excite  the  production  of  antibodies,  or  ambo- 
ceptors, when  it  is  introduced  into  the  body  of  a  living  animal. 

Complement. — That  part  of  a  lysin  which  exists  normally  in 
the  blood-serum  of  all  higher  animals. 

Amboceptor. — That  part  of  a  lysin  which  is  produced  when 
an  antigen  acts  upon  the  body. 

Nature  of  a  Lysin. — A  lysin  is  a  double  substance  and  con- 
sists of  two  parts,  called  complement  and  amboceptor.  Com- 
plement is  the  actual  ferment  and  is  Hke  the  pepsin  of  the  gastric 
juice.  Amboceptor  is  like  the  hydrochloric  acid  of  the  gastric 
juice,  and  its  use  is  to  enable  the  complement  to  act. 

Complement  is  found  in  the  blood-serum  of  all  higher  ani- 
mals, and  has  the  same  nature  in  all  of  them.  Amboceptor  is 
not  normally  found  in  the  blood,  but  it  is  a  specific  substance 
which  is  produced  as  a  result  of  the  introduction  into  the  body 
of  the  foreign  protein,  bacteria,  or  other  antigen.  Each  kind  of 
antigen  produces  its  own  amboceptor  which  acts  only  on  that 


IMMUNITY  149 

particular  antigen.  Neither  a  complement  nor  an  amboceptor 
can  act  alone,  but  the  action  of  each  depends  upon  the  presence 
of  the  other.  An  amboceptor  is  not  affected  by  a  degree  of  heat 
which  destroys  the  complement. 

Complement  Fixation. — When  bacteria  grow  in  the  body, 
they  act  as  an  antigen  and  stimulate  the  body  to  produce  an 
amboceptor  which  connects  or  fixes  the  complement  of  the 
blood  to  the  bacteria.  The  action  of  the  amboceptor  in  joining 
the  complement  to  the  antigen  is  called  complement  fixation; 
and  its  result  is  the  digestion  and  destruction  of  the  antigen  by 
the  complement.  The  principles  of  complement  fixation  are 
applied  in  tests  for  the  diagnosis  of  diseases  and  for  the  identi- 
fication of  unknown  bacteria.  When  the  test  is  made  for  the 
diagnosis  of  a  disease,  the  antigen  consists  of  known  disease  germs 
or  their  products,  the  complement  is  that  in  the  fresh  blood- 
serum  of  a  normal  guinea-pig,  and  the  amboceptor,  if  present, 
is  that  in  the  blood-serum  of  the  suspected  person. 

When  the  test  is  made  for  the  identification  of  bacteria,  the 
antigen  is  the  bacteria  to  be  tested,  the  complement  is  that  in 
the  serum  of  a  normal  guinea-pig,  and  the  amboceptor  is  that  in 
the  serum  of  an  animal  which  has  received  injections  of  a  known 
variety  of  bacteria.  If  the  bacteria  of  the  antigen  are  of  the 
same  variety  as  those  producing  the  amboceptor,  complement 
fixation  will  take  place. 

When  the  red  blood-cells  of  a  sheep  are  injected  into  a  rab- 
bit, they  act  as  an  antigen  which  sensitizes  the  rabbit  and 
causes  it  to  form  an  amboceptor  which  acts  only  on  the  red  cells 
of  sheep's  blood.  If  the  blood-serum  of  the  sensitized  rabbit 
is  mixed  with  the  red  blood-cells  of  a  sheep,  its  amboceptor  and 
the  complement  in  it  will  destroy  the  sheep's  cells.  The  process 
by  which  the  serum  of  an  animal  destroys  the  red  blood-cells 
of  another  animal  is  called  hemolysis,  and  is  a  form  of  comple- 
ment fixation. 

The  action  in  a  complement-fixation  test  is  similar  to  that  in 
hemolysis.  The  antigen  usually  consists  of  disease  germs  or 
their  products.  The  amboceptor  consists  of  the  blood-serum  of 
a  patient  or  a  sensitized  animal.  The  complement  in  the  serum 
is  destroyed,  or  inactivated,  by  heat,  and  in  its  place  a  known 
quantity  of  complement  is  supplied  in  the  form  of  fresh  serum 
from  a  normal  guinea-pig.  Hemolysis  is  used  in  complement- 
fixation  tests  as  an  indicator  of  the  reaction,  for  its  effects  can 
be  seen,  while  most  other  actions  in  lysis  are  invisible. 

The  materials  for  a  complement-fixation  test  for  the  diag- 
nosis of  a  disease  are  two  known  antigens,  one  known  com- 
plement, one  known  amboceptor,  and  one  amboceptor  whose 


150 


THE   HEALTH    OFFICER 


presence  is  uncertain  (that  of  the  suspected  person).  These 
substances  are  arranged  in  two  series  which  may  be  indicated  as 
follows : 


Disease  Products  Scries: 

Antigen. 

(Disease  germs.) 

.Vmboceptor. 

(Blood-scrum  of  the  person 
to  be  tested  heated  to  de-  [ 
stroy  its  unknown  quan- 
tity of  complement.) 


Known      com- 
plement. 
(Guinea-pig 
serum.) 


Hemolytic  Scries: 

4.  .\ntigen. 

(Sheep  red  blood-cells.) 

5.  .Amboceptor. 
(Blood-serum    of   a    rabbit 

that  has  receivetl  an  in- 
jection of  sheep  red  blood- 
cells,  and  has  been  heated 
to  destroy  its  unknown 
quantity  of  complement.) 


A  mixture  of  Nos.  1,  2,  and  3  is  first  made,  and  is  set  aside 
for  some  time  in  order  to  allow  the  antigen,  the  amboceptor  if  it 
is  present,  and  the  complement  to  combine.  No.  4,  or  the  antigen 
of  the  hemolytic  series,  and  amboceptor  No.  5,  are  then  added. 
If  the  person  has  a  disease,  amboceptor  No.  2  will  be  present 
and  the  complement  No.  3  will  become  fixed  to  antigen  No.  1, 
and  will  exhaust  itself  in  destroying  the  disease  germs,  and  will 
not  act  on  the  blood-cells  or  antigen  No.  4.  A  positive  test 
is  thus  indicated  by  a  failure  of  the  red  blood-cells  to  be 
dissolved. 

If  the  person  is  free  from  the  disease,  there  will  be  no  ambo- 
ceptor present  in  his  blood,  and  the  complement  will  not  act  on 
the  disease  germs,  but  it  will  unite  with  the  amboceptor  of  the 
hemolytic  series,  and  will  dissolve  the  red  blood-cells.  The 
absence  of  the  disease  will  be  indicated  by  the  dissolving  action 
on  the  red  blood-cells. 

Complement  fixation  is  the  basis  of  the  Wassermann  test 
for  syphilis,  and  is  also  used  in  diagnosing  gonorrhea,  tubercu- 
losis, and  other  diseases. 

The  health  officers  in  New  York  State  are  supplied  with  out- 
fits for  taking  blood  for  the  Wassermann  and  other  tests.  Each 
outfit  consists  of  a  sterile  glass  tube  and  a  sterile  hypodermic 
needle.  When  blood  is  to  be  drawn,  tie  a  band  around  the 
upper  arm  in  order  to  obstruct  the  flow  of  blood  and  distend  the 
veins.  Paint  the  skin  over  a  vein  with  tincture  of  iodin  in  order 
to  disinfect  it.  Thrust  the  needle  into  the  vein  with  the  slant- 
ing side  of  the  tip  upward,  and  remove  the  band  as  soon  as  the 
blood  appears.  Allow  2  or  3  drams  of  blood  to  flow  into  the 
tube,  cork  the  tube  tightly,  and  send  it  to  the  laboratory. 

Opsonins.— Blood-serum  usually  contains  substances,  called 
opsonms,  which  act  on  bacteria  and  change  them  in  such  a  way 
that  the  phagocytes  digest  them  readily.  If  opsonins  are  ab- 
sent, the  phagocytes  have  httle  or  no  action  on  bacteria  in  the 


IMMUNITY  151 

body.  The  bacteria  of  a  disease  will  usually  stimulate  the  body 
to  produce  the  specific  opsonins  which  will  act  on  that  kind  of 
bacteria. 

The  amount  of  opsonins  in  a  person's  blood  compared  with 
the  amount  in  the  blood  of  a  normal  person  is  called  the  opsonic 
index  of  that  person.  The  material  for  finding  the  opsonic 
index  consists  of — 

1.  White  blood-cells  from  a  normal  person. 

2.  A  pure  culture  of  bacteria. 

3.  Blood-serum  from  the  person  to  be  tested. 

4.  Blood-serum  from  a  normal  person. 

Mix  equal  parts  of  1,  2,  and  3  and  allow  them  to  stand  for 
fifteen  minutes.  Prepare  a  microscope  specimen  of  the  mixture 
and  count  the  average  number  of  bacteria  that  are  enveloped 
by  each  phagocyte.  Prepare  another  specimen,  using  serum 
No.  4  instead  of  No.  3.  The  opsonic  index  is  found  by  dividing 
the  number  obtained  from  the  first  specimen  by  that  from  the 
second.  The  opsonic  test  is  inexact  owing  to  the  lack  of  a 
standard  by  which  to  estimate  the  value  of  normal  serum  and 
leukocytes. 

Ehrlich's  Side-chain  Theory. — Ehrlich's  side-chain  theory  is 
a  means  employed  in  teaching  the  nature  of  some  of  the  factors 
that  are  concerned  in  immunity.  It  makes  use  of  arbitrary 
diagrams  to  indicate  invisible  and  unknown  chemical  actions 
and  products,  and  their  relations  to  one  another  and  to  the  cells 
of  the  body. 

EhrHch  represents  the  cells  as  having  protrusions,  called 
receptors,  which  receive  the  food  and  toxins  and  other  foreign 
substances  that  enter  the  body.  Each  receptor  has  a  peculiar 
shape  and  will  fit  one  kind  of  substance  only,  like  a  key  in  a 
lock.  If  a  receptor  fits  a  substance,  it  holds  the  substance  and 
binds  it  to  the  cell.  This  combining,  or  chaining,  action  of  the 
receptors  gives  the  name  to  the  theory.  A  cell,  for  example, 
takes  a  particle  of  food  because  its  receptor  fits  that  particle  of 
food.  It  fails  to  make  use  of  another  kind  of  food  substance 
because  it  has  no  receptor  which  fits  that  food. 

A  toxin  has  a  poisonous  action  on  a  cell  because  the  cell  has 
receptors  which  fit  the  toxin.  When  the  toxin  joins  a  receptor, 
it  destroys  that  particular  receptor  and  injures  the  cell,  but 
the  cell  repairs  the  injury  by  producing  more  receptors  than  were 
destroyed.  The  cell  also  gives  oft"  receptors,  which  then  float 
free  in  the  blood,  and  are  ready  to  seize  the  toxin  before  it  can 
reach  the  cells  and  injure  them.  The  receptors  floating  free  in 
the  blood  are  antibodies.  They  may  be  considered  to  be  parts 
which  have  left  the  ceU  and  gone  in  search  of  the  enemies  of  the 


152 


THE  HEALTH   OFFICER 


cell.     There  is  an  analogy  between  the  action  of  the  cast-ofif 
receptors  of  cells  and  that  of  the  phagocytes. 

The  simplest  form  of  receptor  is  an  antitoxin,  for  its  only 
action  seems  to  be  to  combine  with  the  toxin  like  a  key  in  a  lock, 
so  that  the  toxin  is  unable  to  attach  itself  to  the  cells.  It  may 
be  represented  by  the  following  diagram: 


%^ 


—Toxin 


-Anhlbxin 


A  second  form  of  receptor  is  an  agglutinin.  An  agglutinin 
receptor  has  one  part  which  combines  with  a  foreign  substance 
and  another  part  which  acts  on  that  substance  and  restrains  its 
motion.  An  agglutinin  may  be  represented  by  the  following 
diagram: 

— L—  &aclefKim 


tL^ 


-FcrtYienl'    oL 
)he.  (\aa\vun\n 


An  amboceptor  consists  of  a  receptor  which  has  two  combin- 
ing parts,  one  of  which  combines  with  the  complement  and  the 
other  with  the  foreign  substance.  It  is  represented  by  the  fol- 
lowing diagram : 


tL^ 


z_^ 


■ Anhoen 
Complement' 


Resistance  to  Disease. — The  resistance  which  a  person  has 
to  an  infectious  disease  and  the  growth  of  disease  germs  depends : 
1,  on  its  general  health  and  vigor  of  the  body;  and  2,  on  the 
presence  of  specific  antibodies  in  the  blood. 

The  diseases  in  which  bodily  health  and  vigor  are  specially 
important  factors  in  prevention  and  recovery  are  sepsis  and 
wound  infections,  and  the  common  respiratory  diseases,  such  as 
colds,  pneumonia,  and  tuberculosis.  The  principal  means  of 
protection  in  these  diseases  is  the  direct  action  of  the  living  cells, 
and  especially  of  the  phagocytes,  upon  the  disease  germs  in  the 
body. 


IMMUNITY  153 

General  health  and  vigor  afford  little  protection  against  in- 
fection with  smallpox,  scarlet  fever,  measles,  typhoid,  and  most 
other  diseases  that  are  usually  classed  as  contagious.  The 
resistance  of  the  body  to  any  one  of  these  diseases  depends 
principally  on  the  presence  of  the  specific  antibodies  of  that  dis- 
ease. 

Effect  of  Cold  and  Dampness. — Cold  and  dampness,  espe- 
cially the  two  combined,  are  popularly  supposed  to  be  the 
principal  causes  of  colds  and  other  respiratory  diseases.  If 
disease  germs  do  not  enter  the  body,  cold  and  dampness  will  not 
produce  a  cold  or  pneumonia.  Explorers  in  Arctic  regions  and 
sailors  on  long  voyages  do  not  have  colds,  although  they  are 
exposed  to  extremes  of  coldness  and  wetness;  but  they  readily 
take  cold  when  they  return  home  where  they  are  exposed  to 
disease  germs. 

There  is  little  scientific  evidence  concerning  the  methods  by 
which  cold  and  dampness  harm  the  body.  Anthrax  germs  will 
not  grow  in  a  normal  fowl,  but  they  may  grow  and  produce 
the  disease  if  they  are  introduced  into  fowls  that  are  kept  stand- 
ing in  cold  water.  The  germs  of  colds  and  pneumonia  are  often 
found  in  the  noses  and  throats  of  carriers,  and  are  unable  to 
grow  until  something  upsets  the  balance  between  their  virulence 
and  the  resistance  of  the  body.  When  a  cold  or  pneumonia 
follows  an  exposure  to  cold  and  dampness,  at  least  three  possible 
explanations  may  be  made:  1,  that  the  defenses  of  the  body  may 
have  been  impaired;  2,  that  the  ordinary  germs  of  the  nose  or 
throat  may  have  acquired  an  increased  virulence;  or  3,  that  a 
new  supply  of  virulent  germs  may  have  entered  the  body.  The 
purpose  of  a  health  officer  is  to  destroy  disease  germs  so  that 
cold  and  dampness  and  other  harmful  influences  cannot  produce 
infections. 

Fatigue  and  Infection. — Experiments  with  rats,  guinea-pigs, 
and  rabbits  have  proved  that  fatigue  lessens  the  resistance  to 
most  kinds  of  infection.  Cells  that  are  exhausted  are  poisoned 
by  their  own  products  and  are  unable  to  produce  a  full  quota 
of  defensive  substances. 

Fatigued  persons  often  neglect  the  finer  points  of  cleanhness 
and  of  precautions  against  disease  germs,  and  thus  they  render 
themselves  liable  to  infection.  The  only  means  of  control 
which  health  officers  have  over  the  fatigue  factor  in  infection  is 
through  some  degree  of  supervision  over  working  conditions  in 
factories  and  workshops,  and  indirectly  through  advice  and 
education. 

Food. — A  considerable  deficiency  of  an  essential  element  in 
the  diet,  as  in  scurvy,  impairs  the  resistance  of  the  body  to  a 


154  THE   HEALTH    OFFICER 

marked  degree.  The  impairment  is  far  less  when  the  diet  is 
deficient  in  quantity  and  yet  contains  all  the  varied  substances 
that  the  body  needs.  Tuberculosis  is  a  common  disease  in 
which  insufiicient  or  improper  food  has  a  direct  etTect  in  de- 
creasing the  resistance  of  the  body.  Improper  nourishment  is 
often  associated  with  poverty,  shiftlessness,  uncleanness,  and 
other  unhealthful  conditions  that  accompany  or  underlie  vicious 
feeding  habits.  Alcohol  especially  lessens  the  resistance  of  the 
body  to  disease. 

Foul  air,  poor  ventilation,  and  the  overheating  of  rooms  are 
conditions  which  have  a  great  influence  in  lowering  the  resist- 
ance of  the  body  to  tuberculosis,  colds,  pneumonia,  and  other 
respiratory  diseases.  These  conditions  also  favor  infection 
through  dust  and  droplets  of  excretions  from  the  nose  and 
mouth.  A  health  officer  has  a  considerable  degree  of  control 
over  these  conditions  through  his  work  among  tuberculosis 
cases  and  through  his  inspection  of  school  rooms  and  other  places 
of  public  assembly. 

Abnormal  Conditions  of  the  Mouth. — Enlarged  tonsils  and 
adenoids  lower  the  resistance  of  the  body  because  of  their  evil 
effects  on  breathing,  nutrition,  and  general  bodily  vigor.  The 
bacteria  of  tonsillitis  and  sepsis  growing  in  cavities  in  the  tonsils 
and  decaying  teeth  produce  poisons  which  exhaust  the  protective 
powers  of  the  body  and  thus  permit  the  growth  of  any  kind  of 
disease  germ  which  may  enter  the  mouth.  A  dirty  mouth  is 
also  a  culture  place  for  many  kinds  of  poisonous  bacteria.  Per- 
sons wdth  adenoids,  enlarged  tonsils,  decayed  teeth,  and  unclean 
mouths  are  far  more  likely  to  catch  diseases  than  those  persons 
whose  mouths  are  normal  and  clean.  A  health  officer  can  dis- 
cover those  defects  by  his  inspection  of  school  children,  and  can 
use  his  influence  to  have  the  conditions  remedied. 

Natural  Immunity. — The  immunity  to  most  diseases  that  are 
classed  as  contagious  depends  principally  on  antibodies  in  the 
blood.  Some  persons  naturally  have  so  great  a  degree  of  im- 
munity to  certain  diseases  that  they  do  not  catch  the  diseases 
when  they  are  exposed  to  them.  For  example,  about  half  of 
all  persons  have  diphtheria  antitoxin  in  their  blood  in  sufficient 
amount  to  protect  them  against  ordinary  modes  of  diphtheria 
infection.  No  person  is  entirely  immune.  An  immune  person 
is  able  to  overcome  the  few  germs  that  are  taken  into  his  body 
at  one  time  during  an  ordinary  exposure  to  infection.  But  any 
person  will  take  a  disease  if  a  sufficiently  large  number  of  the 
germs  of  that  disease  enter  the  body  at  one  time. 

Acquired  Immunity. — Immunity  may  also  be  acquired.  An 
acquired  immunity  is  passive  when  the  antibodies  are  injected 


IMMUNITY  155 

into  the  body,  and  active  when  the  antibodies  are  produced  by 
the  body  itself. 

Passive  immunity  is  produced  by  the  injection  of  antitoxins 
which  are  taken  from  another  person,  or  from  lower  animals. 
It  lasts  for  only  a  few  days  or  weeks,  for  the  substances  which 
are  injected  are  foreign  to  the  body  and  are  soon  expelled,  and 
no  new  ones  are  produced.  An  active  immunity  may  last  for 
months  or  years,  for  the  antibodies  are  native  to  the  body  and 
a  new  supply  is  continually  formed  by  the  cells. 

Active  Immunity. — An  active  immunity  may  be  induced  by 

1.  An  attack  of  a  disease. 

2.  The  injection  of  the  living  germs  of  a  disease. 

3.  The  injection  of  the  dead  germs  of  a  disease. 

4.  The  injection  of  a  toxin. 

Recovery  from  an  attack  of  a  disease  is  necessarily  based  on 
the  abihty  of  the  body  to  overcome  the  germs  of  that  disease. 
The  body  usually  retains  that  abihty  for  a  considerable  length 
of  time  after  recovery.  The  immunity  after  smallpox,  measles, 
scarlet  fever,  mumps,  whooping-cough,  and  chicken-pox  usually 
lasts  a  hfetime.  Immunity  after  diphtheria  lasts  for  only  a 
month  or  two.  Immunity  after  pneumonia,  septic  infections, 
and  malaria  lasts  for  only  a  few  days,  and  is  often  followed  by 
an  increased  susceptibihty  to  the  disease. 

Inducing  immunity  by  producing  an  attack  of  a  disease  was 
often  practised  with  smallpox  before  the  discovery  of  vaccina- 
tion. It  is  still  followed  by  many  persons  with  the  milder  forms 
of  contagious  diseases,  such  as  mumps,  measles,  and  chicken-pox, 
on  the  theory  that  every  person  must  have  the  disease  and  that 
the  sooner  it  is  over  the  better.  This  mistaken  attitude  retards 
progress  in  suppressing  all  forms  of  diseases. 

Immunity  After  Injections  of  Living  Germs. — A  mild  and 
harmless  attack  of  a  disease  will  protect  the  body  as  fully  as  a 
virulent  form  of  a  disease  will  protect  it.  The  body  will  be 
protected  by  the  introduction  of  living  disease  germs  whose 
virulence  and  power  of  growth  have  been  diminished  to  such  a 
degree  that  they  are  barely  able  to  grow.  Yet  these  weakened 
or  attenuated  germs  may  stimulate  the  cells  of  the  body  to  pro- 
duce antibodies  in  as  great  a  quantity  as  an  attack  of  the  disease 
will  produce.  A  preparation  of  hving  germs  used  for  injection 
into  the  body  is  called  a  virus.  Two  diseases  which  a  health 
ofhcer  may  be  expected  to  prevent  by  the  use  of  injections  of 
living  germs  are  smallpox  and  rabies.  The  virus  that  is  used  in 
vaccination  against  smallpox  consists  either  of  smallpox  germs, 
or  of  organisms  similar  to  those  which  produce  smallpox.  They 
are  grown  on  a  calf,  and  are  thereby  weakened  to  such  a  degree 


156  THE  HEALTH   OFFICER 

that  they  produce  only  a  single  sore  when  they  are  introduced 
into  a  person.  Antirabic  virus  contains  gemis  which  have  be- 
come weakened  by  drying,  or  freezing,  or  other  means. 

Vaccines. — A  virus  does  not  act  until  the  few  germs  that  are 
introduced  into  the  body  have  multiplied  to  millions.  A  danger 
in  the  use  of  living  germs  is  that  they  may  multiply  too  much. 
The  use  of  killed  germs  avoids  this  danger,  and  yet  produces 
immunity.  A  preparation  of  killed  disease  germs  used  for  an 
injection  into  the  body  is  called  a  vaccine.  Vaccines  are  used 
for  the  prevention  of  diseases,  for  their  cure,  and  for  the  prep- 
aration of  serums.  A  common  example  of  the  use  of  a  vaccine 
for  the  prevention  of  disease  is  vaccination  against  typhoid 
fever. 

Vaccines  are  of  doubtful  value  in  curing  a  severe  case  of  dis- 
ease. When  a  disease  is  developing  and  the  body  is  not  pro- 
ducing antibodies,  the  introduction  of  a  vaccine  may  rouse  the 
body  to  produce  defensive  substances.  But  there  is  a  danger 
that  the  body  may  fail  to  respond  to  the  stimulation.  If  it  does 
not  respond  and  produce  antibodies,  the  vaccine  will  increase 
the  amount  of  poison  in  the  body,  and  may  do  harm. 

When  disease  germs  grow  in  a  restricted  part  of  the  body 
and  are  surrounded  by  a  wall  of  defensive  tissues,  few  antibodies 
may  be  produced.  A  vaccine  may  then  stimulate  the  body  to 
produce  antibodies,  and  thus  it  may  cure  the  disease.  An  ex- 
ample of  the  good  effects  of  a  vaccine  in  this  class  of  diseases  is 
the  vaccine  treatment  of  boils  that  come  in  successive  crops. 

Killed  bacteria  are  often  injected  into  lower  animals  in  order 
to  produce  serums  and  antitoxins. 

Preparation  of  Vaccines. — The  usual  method  of  producing  a 
vaccine  is  to  grow  a  pure  culture  of  bacteria  on  a  solid  medium, 
wash  the  bacteria  off  with  salt  solution,  and  kill  them  with  heat, 
carbolic  acid  or  other  disinfectant,  and  put  them  in  bottles,  each 
containing  a  definite  number. 

The  dose  of  a  vaccine  is  reckoned  according  to  the  num- 
ber of  bacteria  that  are  given— 100,000,000  to  1,000,000,000  is 
the  usual  dose.  The  injection  of  this  number  of  bacteria  pro- 
duces some  soreness  at  the  place  of  injection  and  a  shght  fever 
which  passes  off  in  a  few  days.  The  dose  is  repeated  every  two 
or  three  days.  Antibodies  begin  to  appear  in  the  blood  in  two 
or  three  days  after  the  injection. 

The  number  of  bacteria  in  a  given  quantity  of  vaccine  is 
determined  by  the  following  method : 

Using  a  capillary  pipet,  take  a  small  quantity  of  vaccine  and 
an  equal  quantity  of  fresh  human  blood,  and  mix  the  two  on 
a  microscope  sHde.     Count  the  number  of  bacteria  in  several 


IMMUNITY  157 

fields  and  the  number  of  red  blood-cells  in  the  same  fields.  There 
are  5,000,000  red  blood-cells  in  each  cubic  millimeter  of  blood. 
The  number  of  bacteria  in  each  cubic  millimeter  of  vaccine  may 
be  estimated  by  the  following  proportion:  The  number  of  red 
blood-cells  counted  is  to  the  number  of  bacteria  counted  as 
5,000,000  is  to  the  number  of  bacteria  in  a  cubic  millimeter  of 
vaccine.  If  we  know  how  many  bacteria  there  are  in  a  cubic 
millimeter  of  vaccine,  we  can  make  a  dilution  which  will  con- 
tain the  proper  number  of  bacteria  in  a  convenient  quantity  of 
vaccine. 

Autogenous  Vaccines. — Some  disease  germs  which  are  classed 
under  a  single  name  may  be  composed  of  subgroups  which  differ 
widely.  Each  subgroup  may  produce  a  special  poison  of  its 
own,  and  the  injection  of  the  bacteria  may  give  rise  to  an  anti- 
body which  acts  on  that  particular  subgroup  and  on  no  other. 
When  a  stock  vaccine  is  used  for  treatment,  it  may  not  contain 
the  variety  of  bacteria  that  are  causing  the  disorder.  This 
difficulty  may  be  overcome  by  growing  a  pure  culture  of  the 
bacteria  taken  from  the  body  of  the  person  to  be  treated,  and 
using  it  to  make  a  vaccine.  A  vaccine  made  from  germs  taken 
from  a  person's  own  body  is  called  an  autogenous  vaccine.  These 
vaccines  are  of  special  value  in  the  treatment  of  chronic  boils  and 
of  suppurating  cavities. 

Mixed  Vaccines. — Vaccines  are  often  manufactured  contain- 
ing several  varieties  of  bacteria  in  the  hope  that  one  of  them 
will  be  identical  with  the  variety  that  is  producing  the  sickness. 
There  is  no  exactness  in  this  method  of  treatment,  and  there  is 
danger  of  adding  to  the  quantity  of  poison  in  the  body  instead 
of  overcoming  that  of  the  disease.  If  the  right  kind  of  bacteria 
are  present  in  the  vaccine,  their  number  is  likely  to  be  too  small 
to  do  good. 

Serums. — The  injection  of  bacterial  vaccines  into  suitable 
animals  causes  the  animals  to  produce  far  more  antibodies  than 
they  need.  A  few  ounces  of  their  serum  may  then  contain 
enough  antibodies  to  immunize  a  person  when  the  serum  is 
injected  into  his  body. 

A  serum  is  either  antitoxic  or  bacteriolytic.  Two  antitoxic 
serums  are  those  of  diphtheria  and  tetanus.  They  act  only 
upon  the  toxins  of  bacteria,  and  do  not  destroy  the  bacteria 
themselves.  Bacteriolytic  serums  act  by  dissolving  bacteria. 
One  of  the  most  successful  bacteriolytic  serums  is  that  used  in 
treating  epidemic  cerebrospinal  meningitis.  Serums  are  also 
produced  for  the  treatment  of  certain  forms  of  pneumonia  and 
of  streptococcic  infections. 

A  serum  is  potent  only  against  the  variety  of  bacteria  with 


158  THE   HEALTH    OFFICER 

which  it  is  produced,  but  if  the  variety  of  bacteria  in  the  body 
is  kinnvn,  its  serum  may  have  great  value. 

Sensitized  Vaccine. — Immersing  a  bacterial  vaccine  in  a 
serum  made  by  injecting  the  bacteria  into  an  animal  may  reduce 
its  poisonous  nature  without  impairing  its  protective  value. 
The  theory  of  the  action  of  the  serum  is  that  it  neutralizes  the 
poisons  of  the  bacteria.  A  vaccine  treated  with  its  protective 
serum  is  called  a  sensitized  vaccine.  Several  kinds  of  sensi- 
tized vaccines  are  on  the  market,  and  the  principal  value  that 
is  claimed  for  them  is  that  they  may  be  used  in  larger  amounts 
than  the  untreated  vaccines. 

Focal  Infections. — A  collection  of  disease  germs  growing  in 
a  small  part  of  the  body  is  called  a  focal  infection.  The  germs 
may  not  produce  pain  at  their  point  of  growth,  and  yet  they 
and  their  products  may  continuously  poison  the  body  and 
produce  headaches,  valvular  heart  disease,  arthritis  deformans, 
and  other  chronic  disorders.  The  white  spots  which  are  often 
seen  on  tonsils  are  the  openings  of  crypts  filled  with  pus  or 
poisonous  matter.  These  tonsils  are  usually  painless,  and  their 
dangerous  nature  is  often  unrecognized.  If  pus  or  plugs  of 
matter  can  be  pressed  from  a  tonsil,  that  tonsil  is  diseased,  and 
is  a  dangerous  source  of  focal  infection. 

Another  common  source  of  focal  infection  is  a  painless  ab- 
scess at  the  root  of  a  tooth.  This  may  usually  be  recognized 
bv  means  of  an  .v-ray  photograph.  Another  source  is  Rigg's 
disease,  or  pus  between  the  edge  of  the  gums  and  the  teeth. 
The  recognition  of  focal  infections,  especially  those  of  the  tonsils 
and  teeth,  is  becoming  more  and  more  the  work  of  the  health 
officer  and  of  the  medical  school  examiner. 


CHAPTER  XV 

THE  PUBLIC  HEALTH  LABORATORY 

A  PHYSICIAN  of  the  eighteenth  century  could  recognize  only 
the  gross  outward  signs  of  fully  developed  diseases.  He  was 
guided  almost  entirely  by  his  clinical  observations,  and  was  like 
a  watchman  standing  at  the  edge  of  the  sea  and  detecting  only 
a  few  large  objects  upon  a  vast  expanse  of  unknown  waters. 
The  discovery  of  exact  methods  of  physical  examination  begin- 
ning early  in  the  nineteenth  century  gave  the  physician  an  enor- 
mously increased  range  of  vision.  He  became  like  an  observer 
upon  a  lighthouse  tower  and  was  enabled  to  detect  hidden  dis- 
eases in  their  incipiency  and  to  institute  measures  for  their  pre- 
vention. When  the  science  of  bacteriology  developed  late  in 
the  nineteenth  century,  the  physician  became  like  an  observer 
upon  an  aeroplane  equipped  with  telescopes  and  wireless  teleg- 
raphy, and  provided  with  life-lines  for  those  in  danger,  and 
bombs  for  the  destruction  of  his  enemies.  General  practi- 
tioners of  medicine  who  do  not  avail  themselves  of  laboratory 
helps  are  Hke  soldiers  who  do  not  avail  themselves  of  aeroplane 
service.  A  few  skilled  workers  in  a  laboratory  may  supply  the 
diagnostic  eyes  for  an  army  of  family  physicians  who  have  neither 
time,  skill,  nor  equipment  for  doing  bacteriologic  and  patho- 
logic work. 

Clinical  observation,  physical  examination,  and  the  detection 
of  bacteria  and  other  abnormal  substances  in  the  tissues  and 
body  fluids  form  a  trio  of  means  by  which  a  modem  physician 
establishes  his  diagnoses  and  bases  his  treatments;  and  a  neglect 
of  any  one  of  the  three  may  lead  to  loss  of  reputation  to  the 
physician,  death  to  the  patient,  and  wide-spread  disease  among 
the  people.  Since  a  health  officer  deals  principally  with  com- 
municable diseases,  he  is  especially  dependent  upon  a  laboratory 
for  the  conduct  of  his  work.  He  cannot  perform  the  duties  of 
his  office  unless  the  service  of  a  pubHc  health  laboratory  is  at  his 
disposal.  Laboratories  have  changed  public  health  work  from 
uncertain  guesswork  and  extravagant  measures  of  prevention  to 
exact  knowledge  of  the  nature  of  diseases  and  accurate  methods 
of  prevention  adapted  to  each  individual  disease.  One  of  the 
duties  of  a  health  department  is  to  provide  laboratory  facilities 
for  dealing  with  the  communicable  diseases  which  are  prevalent 
within  its  jurisdiction. 

159 


160  THE  HEALTH   OFFICER 

The  communicable  diseases  over  which  the  health  officers 
of  New  York  State  have  official  jurisdiction  are  twenty-eight  in 
number,  as  follows:  anthrax,  chancroid,  chickenpox,  cholera 
(Asiatic),  diphtheria,  d\sentery  (ameba  and  bacillary),  epidemic 
cerebrospinal  meningitis,  epidemic  or  streptococcus  (septic)  sore 
throat.  German  measles,  glanders,  gonorrhea,  measles,  mumps, 
ophthalmia  neonatorum,  paratyphoid  fever,  plague,  pneumonia, 
poliomyelitis,  puerperal  septicemia,  rabies,  scarlet  fe\er,  small- 
pox, syphilis,  trachoma,  tuberculosis,  typhoid  fe\"er,  typhus 
fever,  and  whooping-cough.  To  these  other  health  departments 
add  hookworm  disease,  malaria,  and  tetanus.  A  laboratory  is 
of  direct  and  essential  assistance  in  the  diagnosis  or  treatment 
or  prevention  of  all  these  diseases  excepting  chickenpox,  German 
measles,  measles,  mumps,  scarlet  fever,  and  trachoma.  But 
these  six  exceptional  diseases  are  being  investigated  in  labora- 
tories with  a  fair  prospect  that  their  causes  and  natures  will 
soon  be  discovered  and  methods  of  their  direct  control  will  be 
developed. 

Lines  of  Work. — A  public  health  laboratory  usually  conducts 
six  lines  of  work;  1,  bacteriologic  examinations;  2,  chemical 
analyses;  3,  the  production  of  vaccines  and  serums;  4,  field  work; 
5,  research;  6,  education. 

The  greatest  number  of  individual  specimens  received  for 
examination  and  analysis  in  a  public  health  laboratory  are  those 
which  are  derived  from  the  human  body,  and  which  are  ex- 
amined for  the  presence  of  disease  germs,  or  the  products  of 
disease.  A  laboratory  also  makes  bacteriologic  examinations  of 
substances  by  means  of  which  disease  germs  may  be  spread,  and 
particularly  of  water,  sewage,  milk,  food,  and  air.  The  labora- 
tory may  sometimes  examine  these  substances  on  economic 
grounds  also,  especially  if  they  have  an  indirect  bearing  on 
public  health.  Specimens  of  foods  are  often  examined  for  the 
detection  of  objectionable  impurities  and  adulterations,  and  for 
lowered  standards  of  composition;  but  the  usual  rule  is  that  a 
laboratory  of  a  department  of  health  shall  examine  only  those 
specimens  which  have  a  bearing  on  public  health.  It  will  ex- 
amine all  specimens  sent  by  physicians  from  persons  suspected 
of  having  a  communicable  disease,  or  of  being  carriers  of  disease 
germs,  and  specimens  of  water  and  milk  in  which  disease  germs 
may  reasonably  be  suspected.  It  is  not  the  function  of  a  de- 
partment of  health  laboratory  to  make  free  examinations  of 
water,  or  milk,  or  food  for  private  persons.  A  public  health 
laboratory,  for  example,  will  make  routine  examinations  of 
public  water-supplies,  but  not  of  wells  used  as  private  supplies. 

Vaccines  and  serums  are  produced:  1,  for  the  diagnosis  of 


THE   PUBLIC   HEALTH    LABORATORY  161 

diseases,  as  in  the  Widal  test  for  typhoid  fever;  2,  for  the  im- 
munization of  well  persons  against  various  diseases,  such  as 
typhoid  fever,  diphtheria,  and  smallpox;  and  3,  for  the  treat- 
ment of  diseases,  such  as  tetanus  and  cerebrospinal  meningitis. 

Field  work  is  done  in  order  (1)  ta  obtain  specimens  by  the 
more  difficult  or  unusual  operations,  such  as  spinal  puncture  or 
drawing  a  quantity  of  blood;  (2)  to  give  unusual  serums,  such  as 
those  of  pneumonia,  intravenously,  and  of  tetanus  intraspinally; 
(3)  to  make  an  accurate  examination  of  specimens  which  will 
not  stand  transportation,  such  as  the  spinal  fluid  from  a  polio- 
myelitis case;  (4)  to  advise  and  instruct  physicians,  health 
officers,  and  other  public  health  workers. 

Research  work  is  carried  on  for  the  purpose  of  finding  a 
solution  of  difficult  problems  relating  to  the  causes,  prevention, 
and  treatment  of  diseases;  and  also  of  testing  and  confirming  the 
new  methods  that  are  announced  by  other  investigators.  The 
most  accurate  and  skilful  workers  conduct  these  investigations 
and  most  great  advances  in  modern  medicine  are  due  to  their 
painstaking  efforts.  Health  officers  and  physicians  can  assist  in 
the  research  work  by  reporting  unusual  and  interesting  cases  and 
conditions  for  special  investigations  by  the  laboratory,  and  in 
supplying  specimens  from  diseased  lower  animals  which  are 
suspected  of  having  diseases  which  may  be  communicated  to 
man.  It  may  happen  that  any  health  officer  may  be  able  to 
supply  the  data  and  specimens  which  will  lead  to  the  settlement 
of  an  obscure  point  regarding  the  cause,  diagnosis,  treatment,  or 
prevention  of  an  important  disease. 

It  is  not  the  function  of  the  laboratory  to  conduct  investiga- 
tions and  researches  simply  on  account  of  their  scientific  interest. 
Research  work  and  all  other  activities  of  a  public  health  laboreCv 
tory  supported  by  public  funds  must  produce  practical  results 
in  saving  lives  and  preventing  diseases.  The  ideal  worker  in 
a  laboratory  is  one  who  frequently  comes  in  contact  with  phy- 
sicians and  health  officers  in  the  field  and  tests  the  practicality 
of  his  scientific  laboratory  work  by  clinical  experience  at  the 
bedside. 

It  is  the  policy  of  public  health  laboratories  to  secure  the 
widest  possible  use  of  the  means  of  diagnosis,  prevention,  and 
treatment  which  they  can  offer.  Educational  work  is  conducted 
along  three  principal  lines: 

1.  The  announcement  of  results  of  research  work  in  tech- 
nical journals. 

2.  Demonstrations  before  medical  societies  and  articles  in 
medical  journals  on  new  methods  which  physicians,  health  of- 
ficers, and  public  health  nurses  can  use. 


162  THE  HEALTH   OFFICER 

3.  Lectures  before  popular  audiences  and  articles  in  educa- 
tional journals,  magazines,  and  newspapers,  in  order  to  over- 
come popular  prejudices  and  misapprehensions,  and  to  arouse  a 
popular  demand  for  the  use  of  the  means  of  prevention  and 
treatment  which  laboratories  alone  can  furnish. 

Co-ordination  of  Activities. — The  bureaus  of  laboratories, 
communicable  diseases,  and  sanitary  engineering  of  a  depart- 
ment of  health  are  the  three  divisions  with  which  health  oflicers, 
physicians,  and  other  public  health  workers  come  into  the 
closest  contact.  A  health  officer  may  frequently  be  in  doubt 
as  to  which  division  he  shall  refer  a  matter,  such,  for  example, 
as  the  investigation  and  control  of  a  w^ater-borne  epidemic  of 
typhoid  fever.  These  three  divisions  are  closely  interrelated, 
and  each  depends  upon  the  other  for  information  and  decision, 
and  for  the  execution  of  the  measures  which  are  indicated  by 
their  findings.  In  the  investigation  of  water-borne  typhoid,  for 
example,  the  division  of  communicable  diseases  investigates  the 
cases  and  their  sources;  the  division  of  sanitary  engineering 
investigates  and  controls  the  water-supplies  and  methods  of 
sewage  disposal ;  and  the  division  of  laboratories  makes  the  bac- 
teriologic  and  chemical  analysis  of  water,  sewage,  and  human 
specimens,  and  supplies  the  preventive  vaccines.  The  co-ordina- 
tion of  their  activities  and  the  harmonious  co-operation  of  the 
staffs  are  necessary  in  securing  efficiency  in  public  health 
work. 

Diagnostic  Work. — A  health  officer  sends  specimens  from  the 
human  body  in  order  to  determine  (1)  a  diagnosis  at  the  begin- 
ning of  a  disease;  (2)  the  termination  of  the  disease;  (3)  carriers 
of  disease  germs. 

When  a  health  officer  is  called  to  a  suspicious  case  of  sickness 
he  must  consider  the  following  questions: 

1.  Is  the  disease  infectious;  and  if  so,  what  is  the  diagnosis? 

2.  Can  the  laboratory  assist  in  its  treatment? 

3.  Can  the  laboratory  supply  the  vaccines  or  serums  for 
cure,  or  for  preventing  the  disease  in  other  persons? 

The  answer  to  these  questions  will  often  depend  upon  the 
results  of  the  examination  of  specimens  which  are  sent  to  the 
laboratory. 

When  a  person  has  recovered  from  a  disease,  the  health  of- 
ficer will  wish  to  know  if  the  patient  is  free  from  disease  germs, 
and  if  the  danger  of  spreading  infection  is  passed.  The  deter- 
mination of  these  points  may  require  the  examination  of  one  or 
more  specimens  taken  from  the  patient  after  his  apparent 
recovery. 

A  few  persons  continue  to  have  disease  germs  in  their  bodies 


THE   PUBLIC  HEALTH   LABORATORY  163 

after  they  have  recovered  from  a  disease;  and  a  few  others  have 
disease  germs  in  their  bodies  without  contracting  the  disease. 
These  two  classes  of  persons  are  called  carriers.  Almost  the 
only  method  by  which  carriers  may  be  recognized  is  the  labora- 
tory examination  of  specimens  taken  from  their  boflies.  The 
existence  of  healthy  carriers  was  not  suspected  until  it  was 
demonstrated  by  laboratory  methods. 

Specimens  of  water  are  examined  both  chemically  and  bac- 
teriologically  for  evidences  of  pollution  with  human  excretions. 
They  are  also  examined  chemically  for  the  presence  of  sub- 
stances which  make  the  water  unsatisfactory  for  household  use 
in  any  respect. 

Specimens  of  sewage  are  examined  in  order  to  determine  the 
completeness  of  the  process  of  purification. 

The  purity  and  wholesomeness  of  milk  are  determined  prin- 
cipally by  a  bacteriologic  examination. 

Method  of  Sending  Specimens. — Specimens  are  sent  to  a 
public  health  laboratory  on  the  authorization  of  a  health  officer 
or  other  employee  of  a  department  of  health.  Physicians  are 
considered  to  be  unofficial  diagnosticians  for  the  department  of 
health,  and  it  is  their  ptivilege  and  duty  to  communicate  directly 
with  the  laboratory  and  to  send  specimens  and  cultures  taken 
from  their  patients.  A  report  is  sent  to  the  health  officer  as 
well  as  to  the  physicians,  and  such  a  report  is  not  considered  to 
be  a  violation  of  the  confidential  relations  between  a  physician 
and  his  patient. 

Cultures  and  specimens  are  made  with  special  outfits,  and 
are  enclosed  in  special  containers  which  are  supplied  by  the 
laboratory.  The  outfits  are  in  the  standard  forms  which  are 
best  adapted  for  the  preservation  and  transportation  of  the 
specimens,  and  for  easy  examination  by  the  laboratory  workers. 
These  outfits  are  always  to  be  used  except  in  an  emergency  when 
they  cannot  be  obtained.  The  containers  are  designed  to  secure 
the  safety  of  the  specimen  during  transportation.  The  postal 
laws  require  the  use  of  certain  forms  of  containers  for  specimens 
whose  breaking  might  endanger  health.  The  health  officer  is 
the  distributing  agent  for  the  outfits  and  containers.  Every 
health  officer  in  New  York  State  is  expected  to  maintain  a  supply 
station  for  the  free  distribution  of  the  standard  outfits  which 
are  likely  to  be  used  in  his  jurisdiction. 

Every  specimen  sent  to  a  laboratory  must  be  accompanied 
by  a  statement  of  the  essential  facts  regarding  its  source,  and 
by  a  request  for  the  special  examination  which  is  desired.  A 
specimen  is  of  very  little  value  without  this  information,  for  the 
laboratory  worker  may  not  know  what  to  search  for  or  how  to 


164  THE   HEALTH    OFFICER 

interpret  the  findings.  Every  standard  outfit  sent  out  by  a 
department  of  liealtli  contains  a  printed  form  with  blank  spaces 
for  the  required  information. 

A  health  officer  comes  in  contact  with  a  public  health  labora- 
tory principally  by  sending  specimens  for  the  diagnosis  of  com- 
municable diseases  over  which  he  has  jurisdiction.  He  is  also 
the  olhcial  agent  for  the  distribution  of  serums  and  vaccines 
which  the  laboratory  produces.  The  services  which  a  laboratory 
can  render  a  health  officer  or  family  physician  in  each  disease 
may  be  enumerated  as  follows : 
Anthrax. — The  bacteriologic  examination  of  blood  for  diagnosis. 

The  preparation  of  a  curative  serum. 
Chancroid. — The  examination  of  the  discharges  in  order  to  ex- 
clude syphilis. 
Cholera. — The  bacterial  examination  of  the  intestinal  discharges 
for  diagnosis. 
The  preparation  of  a  vaccine  and  serum  for  prevention  and 
cure. 
Diphtheria. — The   bacteriologic   examination   of   specimens  for 
diagnosis. 
Testing  the  virulency  of  the  bacilli  in  carriers. 
The  preparation  of  antitoxin  for  prevention  and  cure. 
The  preparation  of  toxin  for  the  Schick  test  for  immunity. 
The  administration  of  antitoxin  to  difficult  cases  that  can  be 
reached  by  the  laboratory  workers. 
Dysentery.- — The    bacteriologic    examination    of    intestinal   dis- 
charges for  diagnosis. 
Examination  of  blood  for  diagnosis. 
The  preparation  of  a  vaccine  for  preventive  inoculation. 
The  preparation  of  a  curative  serum  for  certain  types  of 
dysentery. 
Epidemic  Cerebrospinal  Meningitis. — The  bacteriologic  examina- 
tion of  the  spinal  fluid  for  diagnosis. 
The  examination  of  nasal  excretions  for  diagnosis. 
The  preparation  of  a  curative  serum. 
The  administration  of  serum  in  cases  accessible  from  the 

laboratory. 
The  establishment  of  a  temporary  laboratory  in  a  locality  in 
which  an  outbreak  occurs. 
Epidemic  or  Streptococcus  (Septic)  Sore  Throat. — The  bacterio- 
logic examination  of  throat  cultures  for  diagnosis. 
The  examination  of  milk  suspected  to  be  the  source  of  in- 
fection. 
Research  work  among  affected  persons  and  dairies  in  order 
to  determine  the  exact  nature  of  the  infection. 


THE   PUBLIC  HEALTH    LABORATORY  165 

Glanders. — The  bacteriologic  examination  of  discharges. 
The  preparation  of  mallein  for  diagnostic  injections. 
Gonorrhea. — The    bacteriologic    examination    of    discharges    for 
diagnosis. 
The  preparation  of  curative  vaccines  and  serums. 
Hookworm  Disease. — The  examination  of  intestinal  discharges 

for  parasites  and  their  eggs. 
Malaria. — The  examination  of  blood  for  the  malarial  organisms. 
The  examination  of  mosquitoes  for  the  identification  of  the 
carriers  of  malaria. 
Ophthalmia   Neonatorum. — The  examination  of  eye  discharges 
for  diagnosis. 
The  preparation  of  packages  of  silver  nitrate  solution  for 
prevention. 
Paratyphoid  Fever. — The  bacteriologic  examination  of  intestinal 
excretions  for  diagnosis. 
The  bacteriologic  examination  of  suspected  food  for  diagnosis. 
The  examination  of  blood  for  diagnosis. 
The  preparation  of  a  preventive  vaccine. 
Plague. — The  bacteriologic  examination  of  discharges  or  blood 
for  diagnosis. 
The  preparation  of  a  vaccine  for  prevention  and  serum  for 
cure. 
Pneumonia. — The  bacteriologic  examination  of  sputum  for  the 
determination  of  the  type  of  the  bacteria. 
The  preparation  of  a  curative  serum. 
The  administration  of  serum  in  accessible  cases. 
Poliomyelitis. — The  examination  of  spinal  fluid  for  diagnosis. 

The  preparation  of  a  curative  serum. 
Puerperal  Septicemia. — The  bacteriologic  examination  of  dis- 
charges for  diagnosis. 
Rabies. — The  examination  of  the  brain  tissues  of  a  lower  animal 
for  diagnosis. 
The  preparation  of  material  for  preventive  injections. 
Smallpox. — The  preparation  of  a  vaccine  for  preventive  inocula- 
tion. 
Syphilis. — The  examination  of  discharges  for  diagnosis  at  the 
beginning  of  the  disease. 
The  examination  of  blood  for  diagnosis  during  the  course  of 

the  disease  (Wassermann  reaction). 
The  preparation  of  a  curative  chemical  compound. 
Tetanus. — The  bacteriologic  examination  of  discharges  from  in- 
fected wounds  for  diagnosis. 
The  preparation  of  antitoxin  for  prevention  and  cure. 
The  intraspinal  injection  of  antitoxin  in  accessible  cases. 


166  THE   HEALTH   OFFICER 

Titbcrculosis. — The   bacteriologic   examination   of   sputum    and 
discharges,  and  of  milk,  for  diagnosis. 
The  preparation  of  tuberculin  for  skin  tests,  and  for  diag- 
nostic injections. 
Typhoid  Fever. — The  bacteriologic  examination  of  intestinal  dis- 
charges, and  of  blood  for  diagnosis. 
The  examination  of  blood  for  diagnosis  (Widal  reaction). 
The  preparation  of  a  preventive  vaccine. 
Typhus   Fever. — The    bacteriologic    examination    of    blood    for 
diagnosis. 
The  examination  of  body  lice  for  signs  of  infection. 
Whooping-cougJi. — The  preparation  of  a  preventive  vaccine. 

Supply  Stations. — A  health  othcer  is  expected  to  maintain  a 
supply  station  at  wliich  physicians  may  obtain  the  laboratory 
outlits  and  preparations.     The  following  is  a  list  of  the  labora- 
tor}'  supplies  which  a  health  officer  may  profitably  carry: 
Diagnostic  Outfits  in  Mailing  Cases: 
Diphtheria  culture-tubes. 
Sterile    bottles    for    feces    from    typhoid,    paratyphoid, 

dysentery,  and  cholera  cases. 
Sterile  bottles  for  blood  in  the  Wassermann  test  for 
s}-philis.     (These  may  also  be  used  for  spinal  fluids 
and  other  Kquids.) 
Sputmii  bottles  for  tuberculosis  examinations. 
Slides  for  collecting  blood  for  the  Widal  test  for  t>'phoid 

fever  and  other  similar  tests. 
Slides  for  smears  of  blood  and  abnormal  discharges. 
Containers   for   water    for    chemical    and   bacteriologic 
examinations. 
Preparations  for  Cure  and  Prevention : 

Diphtheria  antitoxin,  usually  3000  or  6000  units  in  each 

bottle. 
Tetanus  antitoxin,  1500  units  for  prevention,  and   10,- 

000  units  for  cure. 
Packages  of  silver  nitrate  solution  for  the  prevention  of 

ophthalmia  neonatorum. 
Typhoid  vaccine. 
Whooping-cough  vaccine. 
Antimeningitis  serum. 
Smallpox  vaccine. 
Preparations  which  do  not  keep  well,  or  which  are  seldom 
used,  may  be  obtained  by  telegraphing  or  telephoning  to  the 
nearest  laboratory. 

Organization. — The    modern    practice    of    medicine    centers 
around  the  laboratory,  and  a  physician  is  skilful  and  efficient 


THE   PUBLIC   HEALTH   LABORATORY  167 

in  direct  proportion  to  his  use  of  laboratory  methods.  The 
facilities  of  a  public  health  laboratory  for  the  benefit  of  those 
who  cannot  pay  for  the  services  of  a  private  laboratory  are 
necessary  both  in  the  prevention  of  disease  and  also  in  the 
prompt  restoration  of  the  sick  to  health.  It  is  a  measure  of 
direct  economy  to  expend  public  money  in  order  to  bring  labora- 
tory facilities  within  the  reach  of  all  the  people,  thereby  increas- 
ing their  health,  vigor,  and  productive  capacity.  New  York 
State  outside  of  New  York  City  meets  the  need  by  the  estab- 
hshment  of  a  state  laboratory,  and  ten  county  and  twenty  city 
laboratories.  While  these  are  independent  units,  the  state 
laboratory  exercises  supervision  over  them,  insures  a  standard  of 
skill  and  efficiency  among  the  workers,  and  provides  them  with 
standard  serums  and  cultures  for  their  diagnostic  work. 

An  ideal  plan  of  organization  is  that  each  county  or  con- 
venient group  of  counties  shall  make  provision  for  the  prompt 
examination  of  routine  specimens,  such  as  those  from  cases  of 
diphtheria,  typhoid  fever,  and  tuberculosis,  while  the  state 
laboratory  does  the  more  difficult  and  unusual  examinations, 
and  prepares  the  vaccines  and  serums  whose  manufacture  re- 
quires an  elaborate  outfit. 


CHAPTER  XVI 

EPIDEMIOLOGY 

Definitions. — The  suppression  and  prevention  of  diseases 
that  spread  from  person  to  person  was  the  original  duty  of  a 
health  officer,  and  is  still  his  most  evident  work.  A  disease 
belonging  to  this  class  is  kno^vn  by  the  four  names,  catching, 
contagious,  infectious,  and  communicable,  all  of  which  now 
mean  about  the  same  thing,  and  signify  that  the  disease  may  be 
produced  by  a  minute  quantity  of  material  transferred  from  an 
affected  person  to  a  well  one.  The  word  preventable  describes 
these  diseases,  but  it  also  applies  to  many  bodily  diseases  and 
conditions  which  are  not  communicable. 

The  words  epidemic  and  endemic  refer  to  the  prevalence  of  a 
disease  in  a  locaHty.  An  epidemic  disease  which  continues  for 
months  or  years  in  one  locality  is  called  an  endemic  disease, 
and  its  existence  in  any  community  is  an  indication  either  of 
gross  carelessness  or  of  ignorance. 

A  study  of  the  causes,  means  of  transmission,  and  control  of 
infectious  diseases  is  called  epidemiology.  Three  or  four  known 
cases  of  disease  in  a  community  may  be  called  an  epidemic. 
When  an  epidemic  breaks  out,  it  is  the  immediate  duty  of  the 
health  officer  to  discover  its  cause,  and  to  institute  efficient 
means  for  its  control.  His  broader  duty  is  to  prevent  cases  of 
communicable  disease  from  developing  at  all. 

Cause  of  Communicable  Diseases. — The  old  theory  of  the 
transmission  of  disease  was  that  epidemics  and  pestilences  were 
the  result  of  influences  which  were  invisible,  unrecognizable, 
unknown,  and  mysterious.  These  influences  were  supposed  to 
be  emanations  or  exhalations  from  the  bodies  of  the  sick,  or  of 
impalpable  miasms,  spirits,  or  gases  from  the  soil,  stagnant  water, 
and  filth.  They  were  believed  to  have  a  constant  tendency  to 
escape  from  their  places  of  origin,  and  to  fasten  themselves  upon 
innocent  human  victims  who  came  within  their  reach.  The 
supposition  was  that  they  spread  in  circles,  like  the  waves  from 
a  stone  dropped  into  a  still  pond  of  water;  that  they  were  mostly 
air-borne;  and  that  their  spread  was  dependent  largely  upon 
cold,  damp,  stormy  weather.  This  theory  is  still  held  by  many 
people. 

A  health  officer  does  not  deal  with  uncertainties,  but  with 
definite  facts  and  procedures  with  which  he  must  be  familiar. 

i68 


EPIDEMIOLOGY  169 

The  modern  theory  of  the  cause  of  communicable  diseases  may 
be  summarized  in  the  following  statements  of  general  principles 
to  which  there  are  a  few  exceptions: 

1.  Communicable  diseases  are  caused  by  living  organisms 
which  may  be  seen,  recognized,  and  measured. 

2.  The  sources  of  the  organisms  of  human  diseases  are  the 
bodies  of  diseased  human  beings.  But  tetanus,  rabies,  glanders, 
and  anthrax  are  four  human  diseases  whose  germs  usually  origin- 
ate in  lower  animals. 

3.  The  organisms  leave  the  body  with  the  liquid  and  solid 
excretions,  and  with  abnormal  discharges. 

4.  A  communicable  disease  results  from  the  transference  of 
excretions  and  abnormal  discharges  from  the  sick  to  the  well 
over  a  short  and  direct  route  in  which  the  disease  germs  are  able 
to  survive  natural  destructive  influences. 

Portals  of  Entry. — The  portals  of  entry  of  disease  germs  into 
the  body  are  wounds,  and  the  natural  openings  into  the  cavities 
of  the  body,  especially  the  nose  and  mouth.  The  outer  layer 
of  the  skin  is  a  protective  sheet  of  epithelium  which  is  thick, 
horny,  oily,  and  water-proof,  and  is  impervious  to  living  organ- 
isms. Disease  germs  cannot  enter  the  body  through  healthy 
skin,  but  they  may  enter  the  flesh  and  blood  wherever  the 
epithelium  is  cut  or  injured,  or  they  may  be  carried  through  the 
epithehal  barrier  by  the  prick  of  a  needle  or  splinter  or  insect's 
bill  that  makes  a  wound  too  small  to  be  noticed. 

A  continuation  of  the  protective  layer  of  epithelium  extends 
through  the  nose  and  throat  and  forms  an  inner  skin  lining  the 
cavities  of  the  body,  but  in  the  interior  of  the  body  the  epithelium 
is  thin  and  deHcate,  and  readily  absorbs  hquids.  Yet  the  pro- 
tection afforded  by  healthy  epithelium  is  very  great  and  is 
usually  efficient  unless  it  is  injured  in  some  way,  as  by  the  re- 
tained poisons  of  intestinal  diseases  or  by  prolonged  contact 
with  disease  germs  and  their  poisons. 

Enlarged  tonsils  and  adenoids  are  frequently  the  entrance 
places  of  disease  germs  into  the  body,  for  their  protective  layer 
of  epithelium  is  often  thin  and  deficient;  they  are  composed  of 
unhealthy  tissue;  they  He  in  the  direct  path  through  which  food 
and  air  enter  the  body;  and  they  often  contain  crypts  and  folds 
in  which  disease  germs  and  bacteria  of  fermentation  and  decay 
may  multiply  and  produce  poisonous  substances.  Enlarged 
tonsils  and  adenoids  are  of  .great  importance  from  the  point  of 
view  of  the  health  officer. 

Cleanliness  of  the  Mouth  and  Nose. — The  mouth  always 
contains  bacteria  which  find  an  excellent  culture-medium  in  the 
saHva  and  mucus  and  in  the  furry  coating  on  the  tongue.     A 


170  THE  HEALTH   OFFICER 

dirt}-  mouth  is  often  the  breeding-place  of  disease  germs  which 
would  not  find  lodgment  if  it  and  the  teeth  were  clean.  Disease 
germs  often  lodge  in  cavities  in  the  teeth. 

Cleansing  the  tongue  by  rubbing  the  tooth-brush  over  it 
when  brushing  the  teeth  is  an  efficient  means  for  preventing  the 
accumulation  of  disease  germs.  This  procedure  is  especially 
important  during  epidemics  of  colds,  sore  throats,  and  any  other 
form  of  contagious  disease.  Brushing  the  teeth  and  cleansing 
the  mouth  regularly  is  an  essential  measure  of  personal  hygiene 
in  preventing  infectious  diseases. 

Abnormahties  of  the  nose  often  produce  pockets  in  which 
disease  germs  may  lie  and  multiply.  A  stopped-up  nose  is  a 
menace  to  health.  The  treatment  of  nasal  abnonnalities,  blow- 
ing the  nose,  and  the  use  of  a  handkerchief  are  measures  of  the 
first  importance  in  the  prevention  of  contagious  diseases. 

Modes  of  Transference  of  Disease  Germs. — The  prevention 
of  communicable  diseases  consists  in  preventing  the  excretions 
and  discharges  of  any  person  from  entering  the  body  of  any  other 
person.  A  health  officer  must  be  familiar  with  the  life-histories 
of  disease  germs,  and  with  the  routes  which  the  germs  follow 
in  passing  from  the  sick  to  the  well.  The  routes  of  transmission 
of  communicable  diseases  are  either  private  or  public.  The 
private  route  is  that  known  as  personal  contact.  The  principal 
public  routes  are  those  by  means  of  water-supplies,  milk-suppHes, 
food,  and  insects. 

Contact  Infection. — The  most  common  and  direct  method  of 
spreading  disease  germs  from  one  person  to  another  is  by  con- 
tact with  a  person  who  produces  the  germs.  The  list  of  diseases 
which  may  be  spread  through  personal  contact  includes  nearly 
every  one  which  is  communicable.  A  health  officer  must  pay 
special  attention  to  this  method  of  spread  in  measles,  scarlet 
fever,  and  other  eruptive  fevers;  in  colds,  sore  throats,  pneu- 
monia, and  other  respiratory  diseases;  and  in  diphtheria,  typhoid 
fever,  and  dysentery. 

The  three  principal  ways  in  which  contact  takes  place  are: 
1,  face-to-face  or  droplet  infection;  2,  through  the  hands;  3, 
through  articles  soiled  by  excretions. 

Droplet  hifection. — Most  communicable  diseases  may  be 
spread  by  means  of  the  excretions  blown  from  the  nose  and 
mouth  of  an  affected  person  upon  the  face  of  another.  The 
germs  are  not  expelled  by  acts  of  quiet  breathing,  but  by  violent 
explosive  expirations,  such  as  coughing,  sneezing,  spitting,  and 
loud  talking.  Two  persons  face  to  face  are  in  favorable  posi- 
tions for  the  exchange  of  germs.  Actions  which  frequently  bring 
persons  face  to  face  and  favor  contact  infection  are  holding  an 


EPIDEMIOLOGY  171 

infected  child  on  the  lap,  kissing  on  the  mouth,  wrestling,  and 
sleeping  in  bed  with  another  person.  The  distance  which 
germs  ordinarily  travel  is  not  great.  A  person  is  usually  safe 
from  infection  if  he  remains  3  or  4  feet  away  from  one  who  has 
a  contagious  disease.  He  may  come  nearer  with  safety  if  the 
face  of  the  sick  person  is  kept  turned  away  from  him.  The 
principal  diseases  which  are  spread  by  droplet  infection  are  colds, 
sore  throat,  bronchitis,  pneumonia,  grip,  and  other  diseases  of 
the  respiratory  system. 

There  are  many  opportunities  for  contact  infection  among 
children,  for  they  often  put  their  faces  close  together  in  play- 
ing games,  they  laugh  and  shout  into  one  another's  faces,  and 
they  do  not  observe  the  distant  formahties  of  polite  society  as 
adults  do. 

Hand  Injection. — Contagious  diseases  are  often  spread  by 
means  of  the  hands  soiled  by  excretions  of  the  sick.  Those 
who  come  in  contact  with  the  sick  and  then  handle  food  are 
especially  likely  to  carry  germs  to  the  food.  The  habit  of  plac- 
ing the  hands  to  the  mouth  and. nose  is  frequently  the  cause 
of  carrying  infections.  Two  fixed  rules  for  doctors,  nurses, 
and  all  others  who  care  for  cases  of  contagious  diseases  are : 

1.  Do  not  touch  your  nose,  or  mouth,  or  food,  or  drink  if 
there  is  any  suspicion  that  your  hands  are  soiled. 

2.  Wash  your  hands  immediately  after  touching  a  sick  per- 
son or  anything  that  he  has  soiled. 

It  is  surprising  how  great  a  tendency  there  is  of  most  per- 
sons to  touch  and  handle  things  unnecessarily.  A  good  rule  for 
those  calling  on  the  sick  is  to  place  their  hands  in  their  pockets 
and  keep  them  there  through  the  whole  time  of  the  visit. 

Freshly  Contaminated  Articles. — Articles  which  have  recently 
been  soiled  with  fresh  discharges  from  the  sick  may  carry  infec- 
tion. Examples  of  this  method  of  infection  are  drying  the  face 
on  a  towel  which  a  sick  person  has  just  used,  and  eating  from  a 
spoon  from  which  he  has  just  eaten.  Anything  which  passes 
from  the  mouth  and  nose  of  one  person  to  another  without  being 
cleansed  may  carry  the  germs  of  contagious  diseases.  Some 
articles  which  often  carry  infectious  material  are  handkerchiefs, 
dishes,  napkins,  towels,  and  bed  clothing.  An  efl&cient  method 
of  preventing  infection  by  means  of  soiled  articles  consists  in 
washing  and  boiling  the  articles  after  they  have  been  used  by 
the  sick,  and  before  they  are  used  by  anyone  else. 

Common  towels  and  common  drinking-cups  in  public  places 
often  spread  communicable  diseases.  Their  use  is  forbidden  by 
the  sanitary  codes  of  the  City  and  State  of  New  York,  and  there 
is  a  growing  public  sentiment  for  the  observance  of  the  laws. 


172  THE   HEALTH    OFFICER 

Contact  infection  is  probably  the  cause  of  most  epidemics 
which  now  occur  in  the  most  enlightened  sections  of  the  United 
States.  An  epidemic  in  which  the  disease  is  transmitted  by- 
contact  will  be  irregular  in  the  time  and  place  of  its  appearance; 
there  will  be  a  series  or  chain  of  cases  developing  from  previous 
cases;  and  there  will  be  an  absence  of  exposures  to  infected 
milk,  water,  and  other  public  means  of  the  transmission  of 
infection. 

Fomites. — Closely  connected  with  the  transmission  by  con- 
tact is  the  principle  of  transmission  by  fomites.  It  was  fonnerly 
beUeved  that  disease  genns  were  frequently  carried  on  money, 
clothes,  furniture,  and  other  articles  which  were  in  a  sick  room, 
and  yet  were  never  touched  by  the  diseased  person  or  by  excre- 
tions from  his  body.  Things  which  were  supposed  to  attract 
contagious  material  and  to  become  persistent  carriers  of  disease 
germs  under  ordinary  conditions  were  called  fomites.  The 
theory  of  the  transmission  of  disease  by  fomites  has  been  almost 
abandoned,  and  with  it  has  gone  the  necessity  for  oppressive 
quarantine  and  the  destruction  of  property. 

Wounds  are  the  usual  portals  of  entry  for  the  pus-forming 
germs  and  those  of  septicemia  and  s^-philis.  The  principal  dis- 
ease caused  by  wound  infection  with  which  a  health  officer 
has  to  deal  is  tetanus.  The  germs  of  ordinary  fevers,  such  as 
measles,  scarlet  fever,  and  typhoid  fever,  seldom  or  never  enter 
the  body  through  wounds  in  the  skin.  Anthrax,  glanders,  and 
rabies  are  lower  animal  diseases  whose  germs  may  enter  the 
body  through  wounds. 

Water-home  Infection. — A  common  public  means  of  trans- 
mitting communicable  diseases  is  that  by  the  agency  of  public 
water-supphes.  Almost  the  only  diseases  which  are  spread  by 
impure  drinking-water  are  typhoid  fever,  dysentery,  cholera,  and 
other  forms  of  intestinal  disturbances.  The  source  of  disease 
germs  in  drinking-water  is  nearly  always  sewage  or  the  excre- 
tions and  discharges  from  human  beings  who  are  either  sick  or 
are  carriers  of  disease  germs.  When  a  private  water-supply  is 
the  cause  of  a  disease,  the  source  of  the  pollution  may  nearly 
always  be  found  by  an  inspection  of  the  houses  and  ground  within 
a  few  hundred  feet  of  the  source  of  the  water.  A  chemical  and 
bacteriologic  examination  of  a  water-supply  will  reveal  the  pres- 
ence of  small  quantities  of  sewage  and  of  harmless  germs  from 
the  human  intestine  when  they  are  present  in  extremely  small 
amounts  before  the  disease  germs,  which  are  usually  less  resist- 
ant than  the  harmless  living  germs,  can  enter  the  water.  If 
the  common  intestinal  germs  are  present  in  water,  it  would  be 
possible  for  germs  of  intestinal  diseases  to  have  entered  it  also. 


EPIDEMIOLOGY  173 

Water-borne  diseases  were  formerly  common,  but  they  are  now 
becoming  rare  on  account  of  the  supervision  over  water-sup- 
plies, and  of  the  installation  of  efficient  sewage  disposal  plants. 

A  health  ofificer  is  charged  with  the  duty  of  supervising  pub- 
lic water-supplies.  If  a  water-supply  is  impure,  it  is  the  duty  of 
the  health  officer  either  to  secure  a  wholesome  supply  or  to  warn 
the  people  of  the  dangerous  condition  of  affairs  and  to  instruct 
them  how  to  make  their  drinking-water  safe.  Boiling  an  im- 
pure water  is  the  simplest  and  most  efficient  method  of  killing 
disease  germs  in  it. 

If  an  epidemic  is  water-borne,  it  will  break  out  rather  sud- 
denly and  will  be  confined  to  the  district  which  is  supplied  by 
the  water,  and  will  affect  persons  of  all  classes  who  drink  the 
water,  regardless  of  their  other  actions  or  associations.  Most 
pubhc  water-supplies  are  now  supervised  by  the  health  depart- 
ments of  states  and  cities. 

Milk-borne  Diseases. — Communicable  diseases  are  fre- 
quently transmitted  by  means  of  milk.  The  cow  disease  which 
is  most  likely  to  be  transmitted  to  human  beings  by  means  of 
milk  is  tuberculosis.  Nearly  all  other  kinds  of  disease  germs 
that  are  found  in  milk  are  put  into  it  by  human  germ  producers 
or  carriers  among  the  dairymen  and  milk  dealers.  The  disease 
germs  may  multiply  in  milk,  and  this  is  almost  the  only  natural 
culture-medium  in  which  a  multiplication  of  disease  germs  takes 
place  outside  of  the  body.  This  peculiarity  of  milk  makes  it 
necessary  for  a  health  officer  to  maintain  an  efficient  inspection 
of  milk-supplies.  The  means  of  safeguarding  milk  supplies  are: 
1,  the  control  of  all  cases  of  communicable  disease  and  of  carriers 
on  milk  farms  and  among  milk  dealers;  2,  inspection  and  sani- 
tary control  of  dairies  and  creameries;  3,  the  pasteurization  of 
milk  that  is  sold. 

The  diseases  which  the  New  York  State  Department  of 
Health  considers  milk  likely  to  carry  are  cholera,  diphtheria, 
epidemic  sore  throat,  epidemic  cerebrospinal  meningitis,  scarlet 
fever,  typhoid  fever,  and  smallpox. 

Milk-borne  epidemics  are  becoming  more  frequent  owing  to 
the  increased  complication  of  the  manner  of  handhng  milk.  A 
single  diseased  person  on  one  of  the  farms  which  is  producing 
milk  for  a  large  milk  dealer  may  be  the  means  of  spreading  dis- 
ease germs  through  the  whole  milk-supply,  and  of  causing  an 
epidemic  of  dozens  or  hundreds  of  cases.  A  milk-borne  epi- 
demic may  be  recognized  by  its  being  confined  to  persons  who 
take  milk  from  a  particular  dealer,  by  the  sudden  development 
of  a  number  of  cases  at  once,  and  by  the  subsidence  of  the  epi- 
demic when  the  milk  is  stopped  or  the  supply  is  pasteurized. 


174  THE  HEALTH   OFFICER 

Food. — Other  foods  than  milk  may  transmit  diseases  when 
they  are  prepared,  or  ser\-ed,  or  handled  by  some  one  who  is  a 
carrier  of  disease  germs.  The  list  of  diseases  which  are  trans- 
mitted by  milk  will  apply  to  those  transmitted  by  other  foods. 
In  addition  to  these,  human  beings  may  get  trichinosis  by  eating 
the  meat  of  hogs  that  had  the  disease.  Preventive  measures 
against  food-borne  infectious  diseases  is  through  cooking,  and 
the  exclusion  of  infected  persons  from  all  places  in  which  food  is 
handled. 

Insect-borne  Diseases. — Insects  that  bite  may  introduce  dis- 
ease gcmis  into  the  body  b>-  means  of  their  bills  which  pierce 
the  protecting  barriers  of  epithelium.  The  principal  diseases 
which  are  produced  by  biting  insects  are  malaria  and  yellow 
fever  by  mosquitoes,  t>phus  fever  by  Hce,  and  plague  by  fleas. 
It  is  probable  that  bedbugs  and  any  other  biting  insects  may 
also  carry  disease  germs  and  introduce  them  into  the  body, 
especially  since  they  infest  dirty  persons  who  are  likely  to  be 
diseased. 

House-flies  are  often  carriers  of  disease  germs  which  adhere 
to  their  bodies  when  the  liies  crawl  over  filth.  Flies  are  acci- 
dental carriers  of  disease  germs.  They  would  not  have  disease 
germs  on  their  bodies  if  human  beings  had  no  garbage  heaps  or 
foul  collections  of  excretions  on  which  the  flies  can  crawl.  House- 
flics  do  not  bite  or  scratch,  and  so  they  do  not  introduce  the  germs 
directly  into  the  body,  but  they  lea^•e  them  on  food  on  which 
they  alight,  and  on  the  mouths  and  eyes  of  babies.  The  prin- 
cipal fly-borne  diseases  are  typhoid  fever,  infantile  diarrhea,  and 
infections  of  the  eyes. 

Air-borne  Diseases. — It  was  formerly  thought  that  nearly 
every  communicable  disease  was  air-borne ;  but  experience  and 
scientific  investigations  prove  that  the  air  is  almost  entirely 
free  from  disease  germs,  except  the  foul  air  of  very  close  and 
dirty  rooms.  Even  in  foul  air  the  disease  germs  are  usually 
associated  with  gross  particles  of  matter  which  may  be  seen. 
Most  infective  particles  in  the  air  consist  of  moist  droplets  of 
mucus  and  saliva,  but  dry  dust  may  also  contain  living  bacteria 
of  disease  under  favorable  conditions. 

Disease  germs  usually  die  when  they  are  dried,  but  they  may 
remain  alive  for  a  few  minutes  or  hours.  When  a  crowd  gathers 
in  a  close  room,  some  diseased  person  is  likely  to  spit  on  the 
floor.  The  sputum,may  quickly  dry,  and  its  dust  may  be  scat- 
tered through  the  air  before  the  disease  germs  have  time  to  die. 
The  dust  in  the  air  of  that  room  is  very  likely  to  contain  living 
disease  germs.  Any  dust  which  has  been  recently  made  from 
human  excretions  may  contain  living  disease  germs.     Such  dust 


EProEMIOLOGY  175 

may  often  be  found  in  the  foul  air  of  close,  crowded  rooms,  espe- 
cially if  the  persons  in  it  are  dirty  and  careless. 

Foul  odors  are  popularly  supposed  either  to  cause  diseases 
or  to  indicate  the  presence  of  disease  germs.  A  foul  odor  usually 
indicates  the  presence  of  a  putrefying  substance.  But  putre- 
faction usually  takes  place  only  in  the  presence  of  an  abundance 
of  moisture,  and  neither  disease  germs  nor  bacteria  of  any  kind 
pass  into  the  air  from  moist  surfaces.  Even  sewer-gas  is  nearly 
always  free  from  living  organisms  and  cannot  produce  an  infec- 
tious disease.  The  principal  significance  of  foul  odors  from  the 
standpoint  of  public  health  is  that  they  may  indicate  the  pres- 
ence of  human  excretions,  or  of  decomposable  matter  in  which 
house-flies  may  breed. 

Drafts  of  air  in  a  warm  room  are  often  supposed  to  produce 
colds,  sore  throats,  and  pneumonia.  Drafts  themselves  cannot 
produce  a  cold  or  other  infectious  disease  unless  disease  germs 
enter  the  body.  Drafts  are  especially  noticeable  in  hot,  close 
rooms,  but  in  them  disease  germs,  which  are  likely  to  be  present, 
are  suflicient  to  account  for  a  sickness  which  may  seem  to  have 
been  caught  from  the  air. 

Drafts  have  some  effect  on  the  body  at  critical  times,  and 
may  disturb  the  balance  between  the  invading  disease  germs 
and  the  resisting  forces  of  the  body  so  that  the  disease  germs 
may  obtain  a  slight  foothold  and  produce  the  mild  diseases  which 
we  call  colds.  But  any  other  influence  that  weakens  the  body, 
such  as  overwork  or  indigestion,  may  act  upon  the  body  to 
weaken  it  as  a  draft  does.  Colds  are  caught  in  hot,  close  rooms 
without  drafts  as  frequently  as  they  are  in  drafty  rooms.  There 
is  very  Kttle  scientific  knowledge  of  the  effect  of  drafts  on  the 
body,  for  it  is  almost  impossible  to  conduct  experiments  in 
which  all  the  various  conditions  that  exist  in  close,  drafty  rooms 
may  be  estimated  and  controlled. 

Wet  feet  and  damp  clothes  are  also  supposed  to  produce 
colds  and  other  respiratory  diseases;  but  the  evidence  that  they 
do  so  is  as  unscientific  as  the  evidence  that  drafts  produce  disease. 

Climate  and  Weather. — Physicians  formerly  supposed  that 
the  climate  and  the  weather  had  a  dominating  influence  on 
health,  and  was  an  efficient  means  of  producing  colds,  pneu- 
monia, and  other  respiratory  diseases.  That  theory  has  been 
almost  entirely  abandoned  except  its  application  to  tuberculosis. 
Even  in  tuberculosis,  factors  which  are  controllable  have  a  far 
greater  influence  than  the  cHmate  and  weather.  When  weather 
conditions  are  unfavorable,  most  persons  remain  indoors  as 
much  as  possible  where  there  are  abundant  opportunities  for 
infection  from  dirt,  foul  air,  and  close  contact  with  diseased 


176  THE  HEALTH   OFFICER 

persons.  Colds  and  all  other  forms  of  communicable  diseases 
are  more  prevalent  in  winter  than  in  summer  largely  because  in 
winter  people  remain  indoors  where  the  opportunities  for  infec- 
tion are  manyfold  greater  than  they  are  out  of  doors. 

Carriers. — It  would  be  expected  that  a  knowledge  of  the 
nature  of  conmimiicable  diseases  and  of  their  transmission 
would  enable  a  health  officer  to  prevent  the  development  of  all 
communicable  diseases  by  the  efficient  control  and  treatment  of 
every  effected  person.  Health  officers  probably  would  be  able 
to  eradicate  contagious  diseases  if  they  could  know  of  the 
existence  of  every  case.  But  refined  methods  of  diagnosis, 
especial!}'  those  of  the  laboratory,  have  shown  that  many  per- 
sons in  good  health  produce  disease  germs  in  their  bodies.  These 
persons  mingle  freely  with  others  without  taking  precautions 
against  the  spread  of  the  germs.  Well  persons  who  produce 
disease  germs  are  called  carriers.  Persons  who  have  a  com- 
municable disease  in  such  a  mild  form  that  they  continue  to 
mingle  with  other  persons  as  usual,  are  also  classed  as  carriers. 

Disease  germs  in  carriers  are  found  in  at  least  three  locations: 
1,  in  cavities,  such  as  the  gall-bladder  and  the  crypts  of  the 
tonsils;  2,  in  the  outer  layers  of  the  epithelium;  3,  in  abscesses, 
running  sores,  and  discharging  ears.  In  all  these  locations  the 
gemis  are  outside  of  the  flesh  and  blood,  and  yet  in  a  position 
in  which  the  conditions  of  food-supply  and  warmth  are  favor- 
able to  their  growth. 

Most  persons  who  are  carriers  are  themselves  proof  against 
the  disease.  The  defensive  forces  of  their  bodies  are  principally 
in  the  blood,  and  are  able  to  overcome  the  germs  wherever  the 
blood  flows.  Blood  is  absent  from  the  cavities  of  the  body 
and  from  the  outer  layers  of  epithelium.  Disease  germs  may 
therefore  grow  in  these  parts  of  the  body  without  being  able  to 
penetrate  the  flesh,  or  they  may  persist  there  after  the  blood 
has  overcome  them  in  the  flesh. 

The  principal  diseases  which  are  spread  by  carriers  are  diph- 
theria, t>-phoid  fever,  scarlet  fever,  and  epidemic  cerebrospinal 
meningitis. 

The  number  of  carriers  in  a  community  is  often  considerable. 
Diphtheria  carriers  may  probably  be  found  in  every  village,  and 
during  an  epidemic  of  the  disease  the  number  of  carriers  may 
be  several  times  greater  than  the  number  of  persons  who  are 
known  to  be  sick  with  the  disease.  About  1  per  cent,  of  persons 
who  have  had  t\-phoid  fever  continue  to  produce  germs  of  the 
disease  for  weeks  or  months  after  their  recovery. 

Wheru  an  epidemic  of  a  disease  occurs,  there  is  likely  to  be  a 
number  of  mild  cases  in  whom  the  signs  of  the  disease  are  vague 


EPIDEMIOLOGY  177 

and  uncertain,  or  even  almost  absent.  For  example,  many 
cases  of  sore  throat  are  caused  by  unsuspected  diphtheria  or 
scarlet  fever,  and  many  stomach  aches  are  due  to  unsuspected 
typhoid  fever.  Carriers  and  missed  cases  account  for  the  infec- 
tion of  a  very  large  proportion  of  those  who  have  communicable 
diseases. 

The  danger  from  a  carrier  is  the  same  as  the  danger  from  a 
person  whom  the  germs  have  made  sick.  Carriers  usually  pro- 
duce fewer  germs  than  the  sick,  but  the  lesser  danger  on  account 
of  the  number  of  the  germs  is  counterbalanced  by  the  freedom 
with  which  carriers  mingle  with  other  persons. 

The  virulency  of  the  germs  in  carriers  is  sometimes  less  than 
the  virulency  of  germs  in  persons  who  have  a  disease  in  a  severe 
form,  but  sometimes  it  is  fully  as  great.  A  deadly  form  of  scarlet 
fever  is  sometimes  caught  from  a  person  who  has  had  the  dis- 
ease in  an  extremely  mild  form.  The  virulent  strain  of  diphtheria 
germs  which  are  used  by  the  New  York  City  laboratories  was 
originally  taken  from  a  person  who  had  only  a  mild  sore  throat. 

Diphtheria  carriers  constitute  the  greatest  number  of  car- 
riers with  whom  a  health  officer  has  to  deal.  The  danger  from 
these  carriers  depends  largely  on  whether  or  not  the  germs  are 
virulent.  The  virulency  of  the  germs  may  be  determined  by 
injecting  a  culture  of  the  germs  into  a  guinea-pig  or  other  animal, 
and  noting  their  poisonous  effects.  If  the  test  shows  that  the 
germs  are  not  virulent,  the  carrier  is  not  considered  to  be  dan- 
gerous. 

The  duty  of  a  health  officer  is  to  discover  carriers  whenever 
he  possibly  can  do  so.  His  further  duty  is  to  control  them  so 
far  as  may  be  necessary.  A  health  officer  can  choose  between 
two  measures:  1.  He  can  subject  carriers  to  quarantine  and 
other  procedures  which  are  enforced  against  persons  who  are 
actually  sick.  Experience  has  shown  that  this  extreme  degree 
of  control  is  seldom  necessary  or  practical.  2.  A  health  officer 
can  advise  the  carriers  concerning  the  nature  of  their  trouble 
and  the  means  of  preventing  the  germs  from  spreading  to 
others,  and  he  can  keep  them  under  supervision  to  see  that 
they  observe  his  advice.  This  is  the  proper  method  to  adopt 
when  the  carrier  is  a  reliable  person. 

The  means  of  freeing  carriers  from  their  disease  germs  will 
be  discussed  in  the  description  of  the  individual  diseases. 

How  to  deal  with  carriers  is  one  of  the  greatest  problems 
which  confronts  a  health  officer.  Carriers  are  not  sick,  and  they 
often  resent  any  interference  with  their  Hberty.  The  detection 
of  disease  germs  in  their  bodies  is  usually  made  by  a  laboratory 
test  which  the  carriers  cannot  understand.     They  often  ascribe 


178  THE   HEALTH   OFFICER 

measures  of  control  to  personal  animosity  on  the  part  of  the 
health  officer.  It  is  difficult  to  make  people  realize  the  danger 
from  carriers,  for  they  do  not  see  how  disease  germs  can  grow 
in  the  body  when  the  ordinary  signs  of  sickness  are  absent. 
The  control  of  carriers  will  remain  unsatisfactor\'  until  people 
become  educated  concerning  the  problem. 

What  measures  can  the  people  take  to  protect  themselves 
against  the  uncontrolled  carriers  which  are  in  e\'ery  community? 
The  answer  is  that  an  observance  of  modern  standards  of  clean- 
liness, decency,  and  the  rules  of  poHte  society  are  usually  ef- 
ficient protections  against  infection.  For  example,  typhus  fever 
was  common  in  the  days  when  a  louse  on  the  body  was  con- 
sidered no  more  of  a  disgrace  than  a  fly  is  today.  It  disappeared 
when  people  began  to  consider  it  a  disgrace  to  be  lousy.  People 
are  fairly  well  protected  from  infection  when  they  observe  clean- 
liness of  their  persons,  houses,  and  yards,  and  practice  the  cus- 
toms of  polite  society  regarding  the  contact  of  one  person  with 
another. 

Contacts. — When  persons  have  been  exposed  to  communi- 
cable diseases,  it  is  often  a  problem  what  control  to  exercise 
o\Tr  them  from  the  time  of  exposure  until  the  onset  of  the 
sickness.  Many  cannot  tell  whether  or  not  they  have  actually 
been  exposed,  and  many  who  have  been  exposed  do  not  contract 
the  disease.  The  health  officer  will  make  his  decision  according 
to  the  following  principles : 

1.  Immune  persons  who  are  not  carriers  may  be  dismissed 
from  supervision. 

2.  Non-immune  persons  may  be  allowed  their  freedom  up 
to  a  day  or  two  before  the  expiration  of  the  shortest  period  of 
incubation  of  the  disease. 

3.  If  necessary  a  culture  shall  be  taken  or  a  serum  test  made 
in  order  to  determine  -if  the  exposed  person  is  a  carrier  or  has 
had  the  disease. 

4.  A  protective  serum  or  vaccine  shall  be  given  if  possible. 

5.  The  exposed  person  shall  report  to  a  physician  or  the 
health  officer  upon  the  first  signs  of  sickness. 

Procedure  of  Investigation. — If  there  is  an  epidemic  in  a 
community,  a  health  officer  or  epidemiologist  will  investigate 
and  control  it  by  certain  standard  methods  of  procedure,  which 
are:  1,  to  discover  all  the  cases;  2,  to  obtain  uniform  data  from 
each  case;  3,  to  analyze  the  data  in  order  to  determine  the  source 
of  the  infection;  4,  to  apply  the  remedy. 

Finding  Cases.— The  first  duty  of  a  health  officer  in  the 
suppression  of  an  epidemic  is  to  discover  all  the  cases  of  the 
disease  in  his  jurisdiction.     The  probability  is  that  physicians 


EProEMIOLOGY  179 

report  only  those  cases  which  are  well  marked;  that  many  mild 
cases  go  undetected;  that  many  cases  have  no  doctor  call  to 
see  them;  and  that  there  are  a  number  of  carriers  who  have  not 
been  sick  at  all.  It  is  the  duty  of  the  health  officer  to  discover 
as  many  of  the  mild,  missed,  and  carrier  cases  as  possible. 

One  of  the  reasons  that  epidemics  develop  is  that  they 
usually  begin  with  cases  which  are  mild  and  do  not  resemble 
well-marked  cases.  For  example,  smallpox  now  usually  gives 
only  mild  symptoms,  and  the  eruption  only  partially  develops 
as  compared  with  the  virulent  form  of  the  disease  of  years  ago. 
The  epidemic  is  usually  well  under  way  before  the  disease  is 
recognized. 

One  of  the  first  things  which  a  health  officer  will  usually  have 
to  do  in  the  presence  of  an  epidemic  of  one  of  the  rarer  diseases 
is  to  instruct  the  physicians  in  the  methods  of  recognizing  the 
disease.  He  will  endeavor  to  retain  their  goodwill  and  respect. 
He  will  not  chide  them  for  ignorance,  but  will  explain  to  them 
the  new  and  unfamiliar  forms  which  diseases  assume  in  the 
new  conditions  of  modern  civilization.  He  will  also  explain  to 
them  the  use  of  modem  methods  of  diagnosis,  such  as  lumbar 
puncture  in  poliomyelitis.  When  the  physicians  are  all  edu- 
cated in  the  recognition  of  cases,  and  are  willing  to  co-operate 
with  the  health  department  and  report  all  their  cases,  the 
health  officer  may  feel  that  he  has  laid  a  sure  foundation  for  the 
suppression  of  the  epidemic. 

Another  thing  which  the  health  officer  must  do  is  to  make 
an  inspection  for  the  discovery  of  cases  which  are  not  seen  by 
the  physicians.  There  are  a  number  of  mild  cases  and  of  car- 
riers in  nearly  every  epidemic,  and  their  presence  explains  the 
mysteriousness  of  the  origin  of  many  of  the  known  cases.  A 
public  health  nurse  making  a  house-to-house  canvass  is  a  great 
aid  in  finding  cases  which  have  been  missed  or  concealed.  Ru- 
mors of  cases  and  common  gossip  are  clues  which  are  worth 
following  up,  for  they  lead  to  the  detection  of  many  cases  which 
otherwise  would  not  be  discovered. 

Uniform  Data. — The  second  step  in  the  investigation  of  an 
epidemic  is  the  collection  of  answers  to  uniform  questions  which 
are  put  to  each  sick  person.  The  object  is  to  obtain  a  history 
of  the  person  extending  backward  beyond  the  possible  time  of 
receiving  the  infection.  The  questions  will  vary  according  to 
the  disease  that  is  under  investigation,  but  they  will  be  along 
the  following  general  lines: 

1.  Personal  history,  name,  address,  age,  and  sex. 

2.  Date  of  onset  of  the- sickness. 

3.  Contact  with  known  cases. 


180  THE  HEALTH   OFFICER 

4.  Source  of  supplies  of  water,  milk,  groceries,  green  vege- 
tables, and  other  foods  that  arc  eaten  raw. 

5.  Places  visited,  and  meetings,  dinners,  and  other  gatherings 
attended. 

6.  Visitors  received. 

7.  Sanitary  condition  of  the  home  and  working  place.  A 
health  officer  will  obtain  this  data  from  the  reports  of  phy- 
sicians, by  the  investigations  of  public  health  nurses,  and  by  his 
own  inspections.  A  health  officer  will  need  a  considerable  de- 
gree of  skill  and  diplomacy  in  obtaining  the  data,  and  of  judg- 
ment in  judging  the  truthfulness  and  value  of  the  information. 

Analysis  of  the  Data. — The  third  step  in  the  investigation 
of  an  epidemic  is  to  analyze  the  data  in  order  to  discover  some- 
thing in  common  with  all  the  cases  which  will  point  to  the  source 
of  the  infection  and  the  method  of  its  transmission.  The  health 
officer  will  tabulate  the  cases  according  to  the  dates  of  their 
onset,  their  geographic  distribution,  their  school  attendance, 
their  supplies  of  milk  and  water,  and  their  association  with 
previous  cases.  He  will  take  into  consideration  the  period  of 
incubation  of  the  disease,  and  will  lay  special  stress  on  the  ac- 
tions of  the  cases  at  the  time  when  infection  most  probably 
occurred.  There  may  be  a  large  number  of  possible  sources  of 
infection  in  each  case.  The  source  or  route  which  is  common  to 
all,  or  to  a  considerable  number,  will  probably  be  the  principal 
source  or  route  which  the  health  officer  will  have  to  control. 
The  original  source  of  infection  may  be  evident  from  the  outset 
of  the  investigation,  or  its  detection  may  require  a  high  degree 
of  skill  and  judgment,  especially  in  those  diseases  which  are 
spread  by  contact.  The  details  of  the  methods  of  investigation 
will  vary  according  to  the  nature  of  the  epidemic.  They  will 
be  enumerated  in  the  discussion  of  each  disease. 

Two  valuable  devices  in  investigating  and  reporting  an 
epidemic  are  the  graphic  chart  and  the  spot  map.  An  excellent 
form  of  chart  is  that  in  which  the  number  of  cases  developing 
during  each  day  or  week  or  other  period  of  time  is  indicated  by 
the  height  of  a  series  of  black  columns,  one  for  each  period  of 
time.  Such  a  chart  shows  the  progress  of  the  epidemic  and 
the  results  of  the  various  methods  for  its  suppression.  The 
chart  also  has  an  educational  value  to  the  public,  especially 
when  explanatory  remarks  are  printed  on  it.  A  model  form  of 
graphic  chart  is  that  contained  in  the  New  York  State  Health 
News  for  July,  1914,  illustrating  an  epidemic  of  septic  sore  throat. 

A  spot  map  indicates  the  location  of  the  individual  cases  by 
means  of  circles  or  disks.  A  line  connecting  each  case  with  its 
source  of  infection  shows  at  a  glance  the  origin  of  the  case,  and 


EPIDEMIOLOGY 


181 


the  chains  of  secondary  and  tertiary  cases  that  have  developed 
from  each  focus  of  infection.  Such  a  map  is  a  great  convenience 
in  recalling  the  sources  of  the  cases  and  in  demonstrating  their 
origin  and  the  methods  to  be  adopted  for  the  control  of  the 


epidemic.  A  good  example  of  a  spot  map  is  that  in  the  monthly 
bulletin  of  the  Connecticut  Board  of  Health  for  March,  1917, 
illustrating  the  spread  of  smallpox  from  a  single  center. 

Control  of  an  Epidemic. — When  a  health  officer  has  discovered 
the  cases  in  an  epidemic  and  has  determined  the  modes  of  their 


182 


THE   HEALTH    OFFICER 


transmission,  the  method  of  controlling  the  disease  will  be  evi- 
dent. It  may  be  extremely  simple,  as,  for  example,  the  exclu- 
sion of  a  person  with  a  sore  throat  from  a  dairy;  or  it  may  be 
extremely  difficult,  especially  when  the  disease  is  spread  by 


a. 

§ 

1^8 


§ 


'a 


1 


contact  with  carriers.  The  control  of  an  epidemic,  like  that  of 
a  fire,  is  easy  at  the  beginning,  but  is  hard  when  it  has  pro- 
duced a  number  of  mild  cases  and  carriers  which  are  difficult  to 
discover.  The  time  to  begin  active  measures  for  the  discovery 
and  suppression  of  a  contagious  disease  is  when  it  first  appears. 


CHAPTER  XVII 

THE   MANAGEMENT   OF  A   CASE   OF   COMMUNICABLE 

DISEASE 

Duties  of  a  Health  Officer. — The  law  charges  a  health  officer 
with  the  duty  of  protecting  the  public  against  communicable 
diseases.  A  former  interpretation  of  the  duty  was  that  it  meant 
principally  the  maintenance  of  a  forcible  quarantine  of  well- 
defined  cases.  It  is  now  interpreted  to  include  the  diagnosis  of 
suspicious  cases,  the  discovery  and  control  of  contacts,  and 
giving  expert  advice  regarding  the  treatment  of  the  sufferers. 
Diagnosis  and  treatment  are  often  considered  to  be  the  exclu- 
sive rights  and  prerogatives  of  family  physicians.  But  many 
sick  persons  do  not  call  physicians,  and  many  physicians  are 
unable  to  give  their  patients  the  benefits  of  the  best  methods 
of  treatment  without  the  assistance  of  the  health  department. 
It  is  the  duty  of  the  health  officer  to  assist  the  family  physician 
in  the  diagnosis  and  treatment  of  infectious  diseases.  The 
jealousies  and  disputes  which  frequently  arise  between  health 
officers  and  family  physicians  might  be  avoided  if  every  health 
officer  had  the  knowledge  and  skill  which  entitle  him  to  recogni- 
tion as  a  specialist  in  communicable  diseases  and  in  other  Knes 
of  public  health  work. 

Discovery  of  Cases. — A  health  officer  learns  of  the  existence 
of  cases  of  communicable  disease  in  three  ways:  1,  by  the  re- 
ports of  physicians;  2,  by  the  reports  of  laymen,  including  teach- 
ers, parents,  and  other  persons  in  authority;  3,  by  means  of  his 
own  investigations  and  those  of  the  State  Department  of  Health. 

1.  The  laws  of  the  states  usually  require  physicians  to  report 
cases  of  communicable  diseases  to  which  they  are  called.  Some 
physicians  interpret  the  laws  to  mean  that  they  shall  report 
only  those  cases  in  which  they  are  sure  of  a  diagnosis.  But 
many  cases  cannot  be  surely  recognized  until  laboratory  tests 
are  made  or  until  the  disease  is  fully  developed.  Physicians 
frequently  delay  their  reports  for  some  days  during  the  early 
stages  of  a  disease  when  it  is  most  infectious;  or  else,  in  mild 
cases,  they  delay  until  the  symptoms  subside  and  a  diagnosis 
is  impossible.  The  intent  of  the  law  is  that  a  physician  shall 
report  every  case  as  soon  as  he  has  a  well-grounded  reason  to 
think  that  it  may  be  one  of  a  communicable  disease. 

183 


184  THE  HEALTH   OFFICER 

The  health  officer  is  usually  the  official  diagnostician  of  the 
local  health  organization,  and  the  family  physician  has  a  right 
to  demand  that  he  assume  some  of  the  respons'bility  of  diagnosis. 
If  the  health  officer  is  not  an  expert,  the  best  way  to  compel 
him  either  to  become  one  or  to  resign  his  office  is  for  family 
physicians  to  insist  that  he  assume  his  share  of  the  responsi- 
bility in  the  diagnosis  of  every  reported  case.  This  means  that 
the  health  officer  must  see  and  examine  every  case  of  the  more 
important  diseases.  If  he  does  this,  he  will  not  only  aid  the 
physicians,  but  he  will  also  be  able  to  obtain  a  full  knowledge 
of  conditions  in  the  home,  and  to  adopt  measures  that  will  most 
effectively  protect  the  public,  and  at  the  same  time  will  be  least 
irksome  to  the  members  of  the  afflicted  family.  If  the  health 
officer  makes  no  comment  unfavorable  to  the  family  physician, 
but  discusses  the  case  freely  with  hmi  in  private,  there  will  be 
little  opposition  to  his  visits.  In  New  York  City  an  e.xpert 
diagnostician  examines  every  reported  case  of  a  major  com- 
municable disease. 

Physicians  often  refuse  or  neglect  to  report  cases  because 
they  wish  to  protect  the  family  from  annoyance.  They  argue 
that  the  first  duty  of  a  physician  is  to  promote  the  comfort  and 
peace  of  mind  of  the  persons  who  employ  them.  Some  physi- 
cians seem  to  think  that  their  only  duty  is  to  their  employers. 
But  every  physician  owes  a  duty  to  the  state  which  gives  him 
a  monopoly  of  the  practice  of  medicine.  The  people  look  to 
private  physicians  for  protection  against  pestilences.  The  Sani- 
tary Code  of  New  York  State  requires  every  physician  to  in- 
struct his  patients  in  the  methods  for  preventing  the  spread  of 
diseases.  If  a  physician  gives  this  instruction,  there  will  be  no 
occasion  for  undue  interference  by  the  health  officer. 

2.  A  second  method  of  discovering  cases  is  by  following  up 
reports  that  come  to  the  health  officer  from  teachers,  nurses, 
parents,  and  others  than  physicians.  There  are  great  numbers 
of  mild  cases  to  which  no  physicians  are  called.  These  missed 
cases  are  the  means  by  which  communicable  diseases  are  usually 
spread  through  communities  of  intelligent  people,  for  the  severe 
cases  are  in  bed  and  do  not  mingle  with  other  persons. 

Some  persons  deliberately  neglect  to  call  a  doctor  to  mild 
cases  of  contagious  disease  because  they  fear  that  they  will  be 
quarantined.  Drastic  methods  of  quarantine  may  promote  this 
feeling,  but  the  fear  of  the  health  officer  is  disappearing  with  the 
institution  of  rational  procedures  of  isolation,  and  with  the 
spread  of  popular  knowledge  of  the  dangers  which  come  from 
neglected  mild  cases  of  communicable  disease.  The  New  York 
State  Sanitary  Code  provides  penalties  for  the  failure  of  parents 


MANAGEMENT   OF  A   CASE   OF   COMMUNICABLE   DISEASE     185 

or  others  in  authority  to  report  communicable  diseases  among 
those  under  their  charge. 

Common  gossip  and  rumors  are  proHfic  sources  of  informa- 
tion regarding  the  existence  of  cases  of  communicable  disease. 
A  health  officer  neglects  his  duty  if  he  fails  to  follow  up  these 
rumors.  He  will  find  it  extremely  embarrassing  later  to  deal 
with  an  epidemic  whose  source  is  a  neglected  case  which  was 
known  to  everybody  except  himself. 

3.  Health  officers  must  often  make  systematic  investigations 
to  discover  unsuspected  cases  of  communicable  disease,  especially 
during  epidemics.  The  importance  of  mild  and  walking  cases 
of  infectious  diseases  is  becoming  more  and  more  recognized. 
The  refinements  of  modem  diagnostic  methods  and  tests  render 
possible  the  early  detection  of  nearly  every  case. 

One  of  the  most  efficient  agents  in  the  discovery  of  mild  cases 
is  the  pubhc  health  nurse.  Her  information  may  be  obtained 
through  the  schools  or  by  house-to-house  visitations.  She  will 
often  obtain  information  from  neighbors  when  members  of  af- 
flicted famihes  try  to  conceal  cases.  Her  tact  and  persistence 
will  enable  her  to  secure  information  where  the  health  officer 
would  perhaps  fail. 

A  health  officer  is  deeply  concerned  with  discovering  the 
source  of  every  case  of  communicable  disease.  Each  case  has 
an  ancestry  that  extends  backward  in  time  like  an  ancestral 
line  of  parents  and  grandparents.  Its  source  is  a  previous  case 
of  the  same  disease.  It  may  sometimes  be  traced  to  a  lower 
animal  in  a  few  diseases,  such  as  in  rabies,  anthrax,  and  the 
bovine  type  of  tuberculosis ;  but  the  parent  case  is  nearly  always 
that  of  a  human  being.  The  source  of  the  disease  is  a  previous 
case  even  when  the  disease  is  traced  to  water  or  sewage  or  filth, 
for  these  things  produce  communicable  diseases  only  when  they 
receive  germs  from  afflicted  persons.  When  a  communicable 
disease  makes  its  appearance,  a  health  officer  knows  that  it  has 
a  recent  case  for  a  parent,  and  that  he  is  Hkely  to  find  other  cases 
with  the  same  parentage. 

When  an  epidemic  occurs  in  a  community,,  it  is  a  great  prob- 
lem for  the  health  officer  to  discover  the  living  persons  who  are 
spreading  the  germs  of  the  disease.  These  disease  spreaders  are 
usually  either  persons  who  have  had  the  disease  in  a  mild,  un- 
recognized form,  or  who  are  carriers  of  the  germs  (p.  177).  It  is 
important  that  a  health  officer  should  be  familiar  with  the  signs 
of  mild  cases  and  of  those  which  have  apparently  recovered  in 
order  that  he  may  recognize  and  control  them. 

Means  of  Diagnosis. — It  is  the  duty  of  a  health  ofl&cer  to 
secure  a  diagnosis  of  every  suspected  case  of  communicable  dis- 


186  THE   HEALTH    OFFICER 

ease,  lor  the  tinal  decision  rests  with  him.  If  he  cannot  make  the 
diagnosis,  he  must  know  where  and  how  he  can  have  it  done 
promptly  and  accurately.  The  diagnosis  of  the  family  phy- 
sician will  be  accepted  in  most  cases,  but  if  he  and  the  health 
othcer  cannot  agree,  they  can  prevent  ill  feeling  and  promote 
satisfaction  and  co-operation  by  leaving  the  decision  to  a  third 
physician  in  whom  both  have  confidence,  or  they  can  appeal  to 
a  member  of  the  staff  of  the  State  Department  of  Health. 

A  health  oflicer  can  nearly  always  secure  the  assistance  of 
an  expert  diagnostician  from  his  State  Department  of  Health. 
Since  an  obscure  disease  in  a  rural  district  may  be  a  menace  to 
the  people  in  the  cities,  a  health  olhcer  in  an  emergency  can 
usually  obtain  the  services  of  an  expert  from  the  nearest  large 
city. 

A  physician  is  sometimes  inclined  to  yield  to  the  wishes  of  a 
family  and  to  pronounce  a  disease  to  be  non-contagious  unless 
it  has  all  the  classic  SNinptoms  of  the  disease.  The  health  officer 
may  prevent  embarrassment  and  ill  feeling  in  such  a  case  by 
asking  the  family  to  produce  the  written  statement  of  the  family 
doctor  that  the  patient  cannot  give  the  disease  to  another  per- 
son. A  physician  will  not  be  inclined  to  give  such  a  statement. 
If  a  physician  says  that  there  is  no  proof  that  a  patient  has  a 
communicable  disease,  the  health  officer  may  rightly  answer  him 
by  requiring  him  to  give  proof  of  the  absence  of  disease. 

The  diagnosis  of  many  communicable  diseases  is  made  with 
certainty  only  by  means  of  laboratory  tests.  A  health  officer 
is  not  expected  to  be  able  to  perform  the  tests,  but  he  is  expected 
to  know  how  to  secure  the  material  on  which  the  tests  are  made, 
and  where  to  send  the  specimens.  The  New  York  State  Labora- 
tory supplies  the  health  officers  with  outfits  for  taking  material 
for  tests  in  about  a  dozen  diseases,  and  especially  in  diphtheria, 
typhoid  fever,  and  tuberculosis.  The  procedures  for  taking 
the  specimens  are  simple,  and  a  health  officer  has  no  excuse 
for  failing  to  make  full  use  of  the  laboratory  for  obtaining 
diagnoses. 

Preventive  Measures. — After  a  case  of  communicable  dis- 
ease has  been  discovered  and  diagnosed,  the  next  duty  of  a  health 
officer  is  to  prevent  the  disease  from  spreading  to  other  persons. 
The  American  principle  of  personal  independence  does  not 
allow  a  health  officer  to  compel  the  observ^ance  of  measures  to 
prevent  the  spread  of  a  disease  through  the  family  of  the  sick 
person;  but  American  laws  and  customs  prescribe  that  he  shall 
prevent  its  spread  outside  the  family.  The  preventive  measures 
include:  1,  the  control  of  the  sick;  2,  the  discovery  and  control 
of  contacts;  3,  the  disposal  of  infectious  material  that  comes 


MANAGEMENT   OF  A   CASE    OF   COMMUNICABLE   DISEASE      187 

from  the  sick  person;  and  4,  the  disinfection  of  rooms,  furniture, 
clothing,  and  other  things  that  are  used  by  the  sick. 

Control  of  the  Sick. — Since  the  source  of  the  germs  of  human 
diseases  is  the  body  of  a  sick  person,  the  most  obvious  measure 
for  preventing  the  spread  of  a  disease  is  to  restrain  the  liberties 
of  the  sick,  and  to  keep  them  away  from  other  persons.  The 
restrictive  measures  arranged  in  the  order  of  their  degree  of  re- 
straint of  liberty  are:  1,  hospitalization;  2,  quarantine;  3,  isola- 
tion; 4,  modified  isolation;  5,  special  restrictions. 

Hospitals  for  Contagious  Diseases. — The  simplest  method  of 
controlling  afflicted  persons  is  to  remove  them  to  a  special  hos- 
pital for  communicable  diseases.  This  plan  is  economic  in  large 
cities  where  a  supply  of  cases  exists  continuously,  but  it  is  not 
usually  practical  in  the  smaller  cities  and  rural  districts  where 
cases  are  infrequent.  Most  health  officers  must  allow  their 
cases  of  communicable  disease  to  remain  at  home.  It  is  a  trou- 
blesome and  difficult  problem  for  a  health  officer  to  impose 
extreme  restrictions  on  sick  persons  in  their  own  homes  without 
subjecting  them  and  the  members  of  their  famihes  to  great  in- 
convenience. 

Quarantine. — The  greatest  degree  of  home  control  and  re- 
straint is  the  quarantine.  It  requires  that  the  patient  and  all 
those  living  in  the  house  or  apartments  with  the  sick  person 
shall  remain  on  the  premises,  and  that  all  other  persons,  except 
the  physician  and  nurses,  shall  be  excluded.  It  is  directed  not 
only  against  the  sick  person,  but  also  against  the  well  members 
of  the  family  who  happen  to  be  at  home,  and  against  the  house 
and  premises.  The  method  of  control  by  a  strict  quarantine  is 
crude  and  often  cruel,  and  is  usually  unnecessary.  Yet  it  may 
be  efficient,  and  is  the  simplest  and  easiest  of  all  the  methods  of 
control.  It  is  the  method  of  brute  force,  and  would  be  naturally 
adopted  by  a  health  officer  who  is  ignorant  and  lazy,  for  all  that 
he  needs  to  do  is  to  post  a  policeman  at  the  premises,  and  to 
give  an  order  on  a  storekeeper  to  supply  the  necessities  of  life 
to  the  imprisoned  household.  Still,  this  form  of  a  strict  quar- 
antine is  often  necessary  when  the  members  of  the  family  are 
rebellious  and  refuse  to  follow  the  directions  of  the  health  officer. 
It  may  also  be  necessary  in  controlling  those  diseases  w^hose 
causes  are  not  definitely  known.  The  list  of  diseases  in  which 
strict  quarantine  may  be  necessary  includes  smallpox,  t}'phus 
fever,  yellow  fever,  plague,  and  cholera. 

Isolation. — Another  method  of  separating  the  sick  from  other 
persons  is  called  isolation.  It  requires  (1)  that  the  sick  person 
and  the  nurse  shall  remain  in  a  room  that  is  separate  from  the 
rest  of  the  house;  (2)  that  no  other  person,  except  the  medical 


188  IBE  HEALTH   OFFICER 

attendant  and  nurse,  shall  enter  the  room,  and  (3)  that  every- 
thing which  leaves  the  sick  room  shall  be  properly  cleansed  and 
made  free  from  disease  germs.  It  is  a  quarantine  of  the  sick 
person  in  his  room  while  the  adult  members  of  the  household 
who  are  well  are  allowed  their  freedom,  pro\ided  they  do  not 
handle  food  or  come  in  close  contact  with  children.  This 
method  of  controlling  an  infected  person  requires  that  the 
members  of  the  isolated  family  have  a  considerable  degree  of 
intelligence  and  reliability,  and  are  willing  to  follow  directions. 
If  the  people  are  uncleanly  or  unreliable,  the  health  officer  will 
have  to  give  them  the  choice  of  obeying  his  instructions  or  of 
submitting  to  a  strict  quarantine  of  the  house  and  all  the  mem- 
bers of  the  family. 

If  isolation  is  imposed  on  a  person  who  has  a  communicable 
disease,  the  health  officer  must  tell  the  family  what  to  do  and  what 
not  to  do.  He  must  xisit  the  home  more  than  once,  for  few 
persons  will  remember  or  grasp  all  the  directions  which  he  will 
give  unless  he  repeats  or  demonstrates  them.  It  is  the  duty 
of  the  family  physician  also  to  give  these  directions,  but  the 
health  officer  is  responsible  that  they  are  carried  out,  and  he 
must  see  that  the  household  receives  them.  IMany  sick  persons 
have  a  physician  only  once  or  twice,  and  in  these  cases  it  is 
certainly  the  duty  of  the  health  officer  to  see  that  the  directions 
are  carried  out. 

The  list  of  diseases  in  which  the  method  of  control  by 
isolation  of  the  sick  may  be  followed  includes  scarlet  fever, 
diphtheria,  cerebrospinal  meningitis,  septic  sore  throat,  and 
measles. 

Modified  Isolation. — A  strict  isolation  is  not  usually  neces- 
sary in  pneumonia,  typhoid  fever,  paratyphoid  fever,  and 
dysentery.  The  restrictive  measures  that  are  necessary  in  these 
diseases  are  that — 

1.  Well  members  of  the  family  do  not  come  into  close  contact 
with  the  sick. 

2.  The  proper  disposal  of  the  excretions  of  the  sick  is  car- 
ried out. 

3.  A  high  degree  of  cleanliness  of  the  sick  person  and  of  the 
whole  household  and  house  is  observed. 

A  modified  form  of  isolation  may  also  be  permitted  in  the 
minor  communicable  diseases,  such  as  German  measles,  chicken- 
pox,  mumps,  and  whooping-cough.  The  restrictive  measures  in 
these  diseases  are: 

1.  The  sick  shall  remain  on  their  home  premises. 

2.  Those  persons  who  have  not  had  the  disease  shall  be 
excluded  from  the  premises. 


MANAGEMENT   OF  A   CASE   OF   COMMUNICABLE   DISEASE     189 

Special  Restrictions. — Some  diseases  are  not  likely  to  spread 
unless  the  sick  come  into  close  association  with  well  persons  or 
their  fresh  excretions,  as  by  sleeping  in  the  same  bed,  using 
the  same  toilet  utensils,  or  eating  from  the  same  spoon.  A 
person  sick  with  one  of  these  diseases  may  be  allowed  to  mingle 
with  other  members  of  the  household,  or  with  the  public,  pro- 
vided the  special  rules  which  are  necessary  for  that  disease  are 
followed.  Tuberculosis  is  an  example  of  a  disease  in  which 
freedom  in  most  respects  may  be  allowed  to  a  patient  provided 
that  special  precautions  adapted  to  the  individual  are  observed. 

Discovery  and  ContriOl  of  Contacts. — Persons  who  have  not 
had  a  disease  and  have  been  closely  associated  with  a  case  are 
called  contacts,  and  are  to  be  considered  as  in  danger  of  coming 
down  with  the  disease.  It  is  the  duty  of  the  health  officer  to 
discover  these  persons  and  to  inform  them  of  the  possibility  of 
their  having  contracted  the  disease,  and  to  keep  them  under 
observation  during  the  period  of  its  incubation.  If  they  have 
left  town,  it  is  his  ^uty  to  inform  the  health  officials  of  the 
municipahty  to  which  they  have  gone.  The  health  officer  must 
be  the  judge  of  the  likeHhood  of  their  being  infected,  and  of  the 
degree  of  restriction  that  must  be  imposed  on  them. 

Those  who  have  been  in  close  contact  with  a  case  of  com- 
municable disease  and  have  not  taken  the  precautions  to  cleanse 
their  hands  and  clothing,  may  carry  disease  germs  on  their 
persons,  although  this  danger  is  not  nearly  so  great  as  was 
formerly  supposed. 

Special  precautions  are  taken  with  children  living  in  the 
house  with  an  isolated  person  because  (1)  they  are  much  more 
susceptible  to  most  diseases  than  adults,  and  (2)  they  do  not 
have  sufficient  knowledge  and  experience  to  carry  out  the 
health  officer's  directions  of  their  own  accord.  Well  children 
who  are  contacts  and  who  have  not  had  the  disease,  must  be 
held  under  some  degree  of  isolation  and  control  during  the  period 
of  its  incubation  in  order  to  be  sure  that  they  do  not  come  in 
contact  with  others  if  they  come  down  with  the  disease.  They 
may  be  allowed  to  go  to  the  house  of  a  relative  or  friend  where 
there  are  no  children,  provided  they  are  isolated  there.  Child 
contacts  who  have  had  the  disease  may  be  permitted  to  have 
their  freedom,  provided  (1)  that  they  take  a  full  bath;  (2)  that 
they  put  on  clean  clothes,  and  (3)  that  they  leave  the  premises 
of  the  sick  person  and  remain  away  during  the  whole  period  of 
isolation. 

Conduct  of  an  Isolation  Period. — In  choosing  a  room  for 
quarantine  or  isolation,  select  one  that  is  large,  light,  and  airy, 
and,  if  in  winter,  make  provisions  for  warming  it.     If  there  is 


190  THE   HEALTH    OFFICER 

one  person  whose  sole  duty  is  to  care  for  the  patient,  the  room 
had  best  be  up  stairs  and  as  far  removed  as  possible  from  the 
kitchen  and  li\ing  room.  If  the  mother  must  care  for  the  pa- 
tient and  also  do  the  housework,  the  sick  room  had  best  be  on 
the  ground  floor,  while  the  other  members  of  the  family  use  the 
up-stairs  rooms. 

Remo\e  the  carpets,  window  hangings,  clothes,  and  unneces- 
sary furniture  from  the  room.  Cover  the  floor  with  old  news- 
papers, and  use  bed  covers  that  can  be  washed.  Provide  a 
wash  bowl,  towels,  comb  and  brush,  and  other  toilet  articles  for 
the  exclusive  use  of  the  patient,  and  another  set  for  the  attend- 
ant. Provide  the  patient  with  newspapers,  toys,  and  books 
that  can  be  destroyed  at  the  end  of  the  isolation  period.  Have 
an  abundance  of  small  squares  of  muslin  torn  from  old  sheets 
or  other  discarded  muslin,  for  use  instead  of  napkins  and  hand- 
kerchiefs, and  provide  paper  bags  or  newspapers  for  wrapping 
them  up  before  taking  them  away  to  be  burned. 

Instruct  the  nurse  or  attendant  to  wear  a  special  cap  and 
gown  in  the  sick  room,  and  to  wash  her  hands  every  time  she 
touches  the  patient  or  his  excretions.  Instruct  the  attendant 
to  keep  her  lingers  away  from  her  own  mouth  and  nose. 

Disposal  of  Excretions. — Nearly  all  the  germs  that  escape 
from  the  bodies  of  sick  persons  will  be  found  in  their  discharges 
and  excretions.  Anything  that  is  soiled  by  them  may  also  con- 
tain the  germs.  The  principal  discharges  and  excretions  which 
require  attention  are  those  from  the  nose  and  mouth,  those  from 
the  intestine  and  bladder,  and  those  from  sores  on  the  skin.  The 
breath  is  free  from  disease  germs  except  when  it  bears  tiny  drops 
of  saliva  or  mucus  which  are  expelled  by  violent  acts  of  breath- 
ing, such  as  coughing  or  loud  talking.  The  vapors  that  pass 
off  from  the  skin  do  not  contain  disease  germs.  The  touch  of 
an  unbroken  skin  cannot  cause  a  disease  unless  the  skin  is  dirty 
and  soiled  with  the  excretions  of  the  body. 

A  simple  method  of  disposing  of  the  discharges  from  the 
nose  and  throat  is  to  receive  them  upon  paper  napkins  or  rags 
which  are  to  be  burned;  or  upon  handkerchiefs  which  are  to  be 
boiled  and  then  washed.  Warn  the  sick  persons  and  their 
attendants  against  spitting  on  the  floor  or  walls,  or  anywhere 
else  than  into  containers  for  the  sputum. 

A  simple  method  of  disposing  of  the  discharges  from  the 
bowels  and  bladder  is  to  bury  them  at  once  in  the  back  yards. 
Dig  a  hole  about  2  feet  square  and  deep.  Empty  the  discharges 
into  it  and  cover  them  with  a  few  inches  of  soil.  Such  a  hole 
may  be  used  for  several  days  until  it  is  nearly  full.  Do  not  empty 
the  discharges  into  an  ordinary  water-closet  unless  it  has  an 


MANAGEMENT   OF  A   CASE    OF   COMMUNICABLE   DISEASE      191 

underground  vault  which  is  tightly  closed  against  flics  and  ver- 
min. It  is  usually  safe  to  empty  the  discharges  into  a  public 
sewer,  or  into  a  cesspool  that  is  properly  located  and  covered. 
Scald  the  vessel  with  boiling  water  after  emptying  it. 

Disinfection.^ — Three  natural  disinfecting  agents  on  which 
the  health  officer  depends  arc  sunlight,  fresh  air,  and  dryness. 
Disease  germs  are  plants  which  flourish  in  darkness  and  damp- 
ness. Very  few  kinds  can  survive  upon  curtains,  windows,  and 
smooth  walls  that  are  exposed  to  the  light  and  air.  A  wise 
health  officer  will  direct  that  a  sick  room  be  kept  well  venti- 
lated, and  that  it  be  filled  with  as  much  sunlight  as  will  be  com- 
fortable for  the  patient. 

Cleanliness. — Three  artificial  agents  for  disinfection  are 
cleanliness,  heat,  and  chemicals.  Whatever  is  soiled  with  the 
discharges  from  the  body  of  a  sick  person  may  contain  germs  of 
disease,  and  so  the  things  which  the  sick  person  uses  might 
transmit  the  disease  unless  they  are  cleansed.  The  danger 
consists  in  the  presence  of  living  germs  and  not  of  the  dirt  itself. 
Disease  germs  as  well  as  dirt  will  be  removed  by  the  use  of  soap 
and  water,  the  scrubbing-brush,  and  the  wash-tub.  A  funda- 
mental condition  on  which  a  health  officer  will  insist  is  cleanli- 
ness. This  includes  cleanliness  of  the  body,  especially  of  the 
hands  and  face;  of  the  bed-clothing,  bedding,  dishes,  and  every- 
thing else  in  the  sick  room;  and  of  the  attendants  as  well  as  the 
sick  persons. 

Heat  is  the  most  reliable  and  efficient  disinfecting  agent  that 
we  have.  It  is  also  one  of  the  cheapest  and  most  easy  to  apply. 
A  boiling  temperature,  212°  F.,  will  kill  most  disease  germs  in 
a  few  seconds.  If  only  a  small  quantity  of  boiling  water  is  poured 
over  articles,  the  water  will  be  cooled  and  the  temperature  of 
the  disease  germs  will  be  much  lower  than  that  of  boiling.  A 
temperature  of  at  least  140°  F.  is  needed  to  kill  ordinary  disease 
germs.  The  highest  temperature  which  a  person  can  usually 
endure  with  the  hands  is  only  120°  F.  A  safe  order  which  a 
health  officer  may  give  is  to  direct  that  dishes,  towels,  hand- 
kerchiefs and  bed-clothes,  and  all  other  articles  in  common  use 
shall  be  boiled  before  they  are  washed.  After  they  have  been 
boiled,  they  will  be  free  from  disease  germs,  and  may  be  put  with 
the  household  articles  that  are  used  by  the  other  members  of 
the  family.  A  good  method  of  applying  heat  is  to  keep  a  large 
kettle  of  hot  water  boiling  on  the  kitchen  stove,  and  to  place  in 
it  all  small  articles,  such  as  knives,  forks,  dishes,  and  napkins, 
as  soon  as  they  are  taken  from  the  sick  room.  Laundry  articles 
may  be  placed  in  a  wash-boiler  in  the  sick  room,  and  then  boiled 
at  once  on  the  kitchen  stove. 


192  THE  HEALTH   OFFICER 

Chemicals. — Chemical  disinfectants  are  great  aids  in  de- 
stroxing  disease  gemis,  but  the}'  cannot  entirely  take  the  place 
of  cleanliness  and  heat.  They  may  be  unnecessary  if  a  high 
degree  of  cleanliness  is  observed,  but  yet  it  is  well  to  use  a 
chemical  disinfectant  in  the  water  which  is  used  in  cleansing. 

Formaldehyd  is  an  excellent  disinfectant  for  household  use 
in  a  communicable  disease.  It  is  the  least  poisonous  of  the 
common  disinfectants,  and  the  least  hamiful  to  clothes  and 
metals.  A  2  per  cent,  solution  is  to  be  used  in  washing  the 
hands  and  in  scrubbing  floors  and  furniture.  Soiled  clothes 
may  be  soaked  in  a  pail  of  this  solution. 

It  is  a  good  plan  for  the  health  officer  to  have  a  large  supply 
of  formaldehyd  on  hand,  and  to  deli\'er  a  quart  to  each  family 
in  which  there  is  a  communicable  disease.  The  disinfection  is 
for  the  benefit  of  the  public  as  well  as  of  the  afllicted  family,  and 
it  is  therefore  proper  that  it  should  be  provided  at  public  expense 
to  those  who  cannot  well  afford  to  buy  it. 

Other  good  disinfectants  are  chlorid  of  lime,  bichlorid  of 
mercury,  and  substances  belonging  to  the  carbolic  acid  and 
cresol  groups.  It  is  the  duty  of  the  health  officer  to  give  specific 
directions  for  the  preparation  and  use  of  each  kind  of  disinfectant 
that  he  orders. 

Terminal  Disinfection. — If  the  proper  care  is  taken  contin- 
uously during  the  course  of  a  sickness,  there  will  be  no  disease 
germs  left  in  the  sick  room  at  the  end  of  the  disease.  But  in 
order  to  make  sure  that  all  the  disease  gemis  have  been  destroyed 
a  health  officer  will  require  that  the  room  and  its  contents  shall 
be  disinfected  before  the  sick  person  is  released.  There  are 
three  common  methods  of  disinfection:  first,  a  thorough  house- 
cleaning;  second,  scrubbing  with  a  disnifectant;  and  third, 
fumigation  with  a  disinfectant.  A  health  officer  seldom  has  the 
facilities  for  doing  a  thorough  fumigation;  and  if  it  is  not  thor- 
oughly done  it  leads  to  a  false  idea  of  security.  But  a  health 
officer  can  always  get  a  thorough  housecleaning  done,  and  can 
have  a  disinfectant  added  to  the  water  which  is  used.  A  liquid 
disinfectant  rubbed  upon  the  floors  and  furniture  is  far  more 
effecti\'e  than  a  gaseous  one  blown  upon  them. 

Personality  of  the  Health  Officer. — A  quarantine  or  isolation 
usually  requires  that  the  ordinary  home  life  be  upset.  The 
details  of  the  isolation  will  often  depend  on  the  arrangements 
which  the  health  officer  and  attending  physician  can  make  with 
the  family.  Each  case  must  be  judged  by  itself,  and  due  consid- 
eration must  be  given  to  the  character,  personal  habits,  occupa- 
tion, and  financial  means  of  the  wage-earners.  Imposing  an 
isolation  or  quarantine  requires  tact,  diplomacy,  and  good  judg- 


MANAGEMENT   OF  A   CASE    OF   COMMUNICABLE   DISEASE     193 

ment  on  the  part  of  the  health  oiSicer.  If  he  is  imperious  in  his 
manner  and  loud  voiced  in  his  talk,  he  is  sure  to  arouse  antago- 
nism, and  to  encourage  the  concealment  of  cases  and  the  evasion 
of  restrictions.  He  must  be  willing  to  devote  a  considerable  time 
to  educating  those  who  are  subjected  to  his  orders,  and  to  take 
the  trouble  to  explain  the  reasons  for  the  particular  restrictions 
which  he  imposes. 

Methods  of  Legal  Procedure. — The  restrictions  upon  a  per- 
son who  has  a  communicable  disease  are  serious  legal  procedures 
in  which  the  health  ofhcer  is  the  prosecuting  officer,  the  chief 
witness,  and  the  judge.  A  health  officer  deprives  a  person  of 
his  liberty  without  going  through  the  slow  form  of  a  trial;  but 
the  quarantined  person  may  appeal  from  the  decision  and 
bring  a  court  action  for  illegal  detention.  The  health  officer 
must  be  prepared  to  show,  first,  that  he  complied  with  the  forms 
of  law  in  all  his  acts;  and  second,  that  the  evidence  was  sufficient 
to  have  led  a  judge  of  a  court  to  impose  the  restrictions  if  the 
case  had  originally  come  before  him  for  trial. 

The  legal  procedures  which  a  health  of^^  cer  must  follow  in 
the  control  of  a  case  of  communicable  disease  are:  1,  securing 
evidence  of  disease;  2,  informing  the  sick  person  or  the  family 
regarding  the  preventive  measures;  and  3,  supervising  the  con- 
trol of  the  disease  during  its  whole  course. 

Diagnosis. — The  evidence  of  the  existence  of  a  communicable 
disease  will  usually  consist  in  the  report  of  the  family  physician; 
but  it  may  be  supplemented  by  his  own  examination  and  that  of 
an  expert  diagnostician,  and  also  by  the  examination  of  a  speci- 
men in  a  laboratory.  If  this  evidence  proves  the  existence  of 
disease,  the  health  officer  may  impose  the  proper  restrictions 
without  fear.  If  the  evidence  is  insufficient  or  obscure,  the 
health  officer  cannot  legally  compel  the  observance  of  the  re- 
strictions unless  his  Board  of  Health  especially  authorizes  him 
to  apply  them  in  suspicious  cases;  but  it  is  his  duty  to  inform 
the  family  of  his  suspicions,  and  to  advise  them  regarding 
the  protective  measures  to  adopt  while  a  decision  is  being 
reached. 

Imposing  Restrictions. — The  second  formal  procedure  which 
a  health  officer  must  take  to  make  the  restrictions  legal  is  to 
make  a  proper  record  and  report  of  the  case,  and  to  inform  the 
affiicted  persons  of  his  decision  and  tell  them  exactly  what  they 
must  do.  This  action  is  similar  to  that  of  sentencing  a  prisoner 
in  a  law  court.  Troubles  with  quarantines  and  isolations  fre- 
quently arise  from  a  failure  of  those  aftected  to  understand  what 
is  required  and  the  reasons  for  the  requirements.  A  health 
officer  must  usually  spend  a  considerable  time  in  giving  detailed 

13 


194  THE   HEALTH    OFFICER 

directions  in  each  case  of  communicable  disease.  Many  depart- 
ments of  health  require  health  officers  to  give  each  afflicted  per- 
son a  printed  pamphlet  which  describes  the  measures  to  be  fol- 
lowed in  his  disease.  Most  boards  of  health  require  a  health 
officer  to  post  a  placard  informing  the  public  of  the  existence 
of  a  contagious  disease  in  a  house.  This  notice  is  necessary  in 
order  to  relieve  the  quarantined  persons  of  responsibility  if  any 
one  enters  the  house  without  their  knowledge.  It  also  serves 
as  a  formal  notice  to  those  quarantined  that  they  must  obey  the 
law. 

Supervision. — A  third  legal  procedure  is  the  execution  of  the 
judgment  or  sentence.  It  is  the  duty  of  the  health  officer  to 
super\-ise  the  restrictions  during  the  whole  period  in  which  they 
are  in  force.  He  may  leave  the  details  of  this  duty  to  the  family 
physician,  or  to  the  public  health  nurse,  or  to  an  inspector,  or 
he  may  receive  frequent  reports  from  some  member  of  the  family. 
Misunderstandings,  quarrels,  and  lawsuits  often  develop  .from  a 
failure  of  a  health  officer  to  inform  afflicted  persons  of  the  course 
of  the  disease,  and  of  the  varying  restrictions  that  are  needed. 
A  wise  health  officer  will  make  every  effort  to  secure  the  intelli- 
gent co-operation  of  all  the  members  of  the  family  who  are 
under  quarantine  or  isolation. 

Restrictions  are  usually  imposed  for  an  indeterminate  period, 
and  a  release  depends  not  only  on  the  recovery  of  the  patient 
but  also  on  the  absence  of  disease  germs  from  the  patient  and 
from  everything  around  him.  The  health  officer  is  the  judge  of 
the  time  for  release,  but  many  health  boards  fix  minimum  periods 
for  the  continuance  of  the  restrictions  in  each  disease.  The 
health  officer  may  accept  the  evidence  and  the  opinion  of  the 
family  physician,  but  the  final  permission  for  the  release  from 
restrictions  lies  with  him  and  not  with  the  family  physician. 

Since  persons  under  restriction  for  a  communicable  disease 
may  be  deprived  of  their  means  of  livelihood,  it  is  a  principle 
of  law  that  the  public  shall  supply  them  with  food,  fuel,  and 
other  means  of  subsistence  that  are  needed. 

If  a  person  refuses  to  obey  restriction,  the  health  officer  may 
employ  guards  to  enforce  his  orders,  but  if  he  does  so,  he  must 
be  doubly  sure  of  his  legal  evidence.  In  extreme  cases,  a  health 
officer  may  have  to  obtain  a  warrant  for  the  arrest  of  an  of- 
fender, and  if  he  does,  he  must  observe  the  forms  of  the  law  in  all 
his  acts.  Most  persons  are  willing  and  anxious  to  observe  the 
rules  and  regulations  of  the  Department  of  Health.  A  health 
officer  has  recourse  to  the  law  courts  so  seldom  that  he  is  likely 
to  forget  the  forms  of  law,  and  to  neglect  some  formal  procedure 
which  is  necessary  to  make  his  acts  legal  beyond  question. 


MANAGEMENT   OF  A   CASE   OF   COMMUNICABLE   DISEASE      195 

Justices  of  the  peace  sometimes  refuse  to  hear  evidence 
against  quarantined  persons,  fearing  that  they  will  catch  the 
disease.  A  judge  can  hold  court  in  any  place  that  he  pleases, 
and  can  conduct  a  trial  on  the  sidewalk  in  front  of  a  quarantined 
house  as  legally  as  he  can  in  a  court  room.  It  is  the  duty  of 
every  officer  of  a  court  to  give  the  health  officer  every  possible 
assistance.  The  court  officer  is  in  no  more  danger  than  the 
health  officer. 


CHAPTER  XVIII 
THE  MINOR  COMMUNICABLE  DISEASES 

MEASLES 

Measles  is  caused  by  an  in\'isible  virus  which  has  been 
shown  to  pass  through  porcelain  filters.  The  disease  may  be 
given  to  monkeys  by  the  injection  of  blood  from  a  person  who 
has  measles.  The  virus  is  also  contained  in  the  discharges  of 
the  nose  and  mouth,  and  may  be  con\'eyed  to  a  distance  of  4 
or  5  feet  by  droplets  expelled  during  coughing  or  sneezing. 
Measles  is  the  most  infectious  of  all  the  common  diseases,  and 
nearly  all  non-immune  persons  catch  it  after  direct  exposure  to 
a  person  who  has  the  disease.  A  lifetime  immunity  usually 
follows  an  attack  of  measles,  but  people  often  report  that  a  child 
who  has  the  measles  has  had  the  disease  previously.     Some 


DIRECT 


HUMAN   CASE 


Fig.  4. — Method  of  transmission  of  measles,  German  measles,  mumps,  and  chicken- 
pox. 

people  pronounce  any  marked  skin  eruption  accompanied  by 
fever  to  be  measles.  They  frequently  confound  hives  and  Ger- 
man measles  with  measles. 

Course  of  Measles. — The  period  of  incubation  after  exposure 
to  measles  is  about  two  weeks,  but  may  be  scarcely  more  than 
one  week.  The  first  s\Tnptoms  of  the  disease  are  those  of  an 
ordinary  cold  in  the  head,  and  consist  of  sneezing,  coughing, 
running  nose,  and  red  eyes.  A  fever  is  present  within  a  few  hours 
after  the  beginning  of  these  signs.  These  indefinite  s>Tnptoms 
last  for  four  or  five  days,  and  then  an  eruption  of  red  papules 
appears  on  the  forehead,  and  soon  spreads  over  the  body.  But 
196 


THE  MINOR   COMMUNICABLE  DISEASES  197 

an  eruption  on  the  inner  surface  of  the  cheeks  usually  appears 
on  the  second  or  third  day  after  the  signs  of  cold  appears.  This 
early  eruption  consists  of  Koplik  spots,  each  of  which  is  rose 
red,  is  about  j\  inch  in  diameter,  and  has  a  minute  whitish 
center.  They  are  usually  few  in  number  and  are  located  oppo- 
site the  molar  teeth,  but  they  may  be  abundant  and  confluent. 
They  are  best  seen  in  strong  daylight  by  pressing  the  cheeks 
open  with  a  spoon  handle.  They  usually  disappear  soon  after 
the  skin  eruption  appears. 

The  eruption  on  the  skin  lasts  from  four  to  six  days,  and  is 
followed  immediately  by  a  fine  desquamation  of  the  skin.  This 
desquamation  is  in  contrast  with  that  in  scarlet  fever,  in  which 
the  desquamation  appears  after  two  weeks  or  inore,  and  is  coarse 
and  often  consists  of  sheets  of  skin. 

Complications. — Measles  often  produces  pneumonia,  kidney 
diseases,  and  earache  and  running  ears,  especially  in  poorly 
nourished  children.  These  complications  frequently  cause  death. 
More  deaths  in  New  York  State  are  caused  by  measles  than  by 
scarlet  fever.  The  disease  is  dangerous,  and  there  is  good  reason 
for  taking  all  possible  precautions  against  its  spread. 

Management  of  a  Case.^Measles  is  a  reportable  disease, 
and  every  case  requires  isolation  from  all  persons  who  have  not 
had  the  disease.  The  sanitary  code  of  New  York  State  requires 
the  placarding  of  a  house  in  which  the  disease  exists.  The 
period  of  isolation  is  seven  days  from  the  appearance  of  the  rash, 
and  until  all  discharges  from  the  nose,  ears,  and  throat  have 
disappeared,  and  until  the  cough  has  ceased.  The  virus  is  not 
long  lived,  and  strict  cleanliness  is  sufficient  to  kill  the  germs 
that  are  given  off  from  the  patient. 

Epidemiology. — Health  officers  often  express  their  feelings  of 
helplessness  when  they  are  confronted  with  an  epidemic  of 
measles.  They  usually  expect  an  epidemic  to  continue  until 
every  child  who  has  not  had  the  disease  previously  shall  have 
come  down  with  it.  But  it  is  possible  to  control  an  outbreak 
by  the  application  of  modern  methods  for  its  suppression. 

The  prevention  and  control  of  measles  are  peculiarly  difficult 
for  two  reasons:  First,  many  persons  neglect  to  co-operate  with 
the  health  officer  in  suppressing  the  disease  because  they  believe 
it  to  be  more  annoying  than  dangerous.  Those  who  fear  vacci- 
nation will  often  expose  their  children  to  measles  in  order  that 
they  may  have  the  attack  which  it  is  supposed  will  certainly 
come  at  some  time  in  their  lives.  Securing  the  co-operation  of 
the  pubhc  is  the  first  essential  procedure  in  suppressing  an 
epidemic  of  measles. 

A  second  obstacle  in  the  suppression  of  measles  is  the  dif- 


198  THE  HEALTH   OFFICER 

ficulty  of  recognizing  the  disease  during  the  first  four  or  five 
days  after  its  onset.  This  is  the  period  when  the  gemis  are 
given  off  in  the  greatest  abundance  and  most  virulent  fonn. 
^lost  cases  are  caught  from  children  who  mingle  with  their 
playmates  "during  the  period  when  their  symptoms  are  those  of 
a  common  cold.  When  measles  is  prevalent  in  a  community, 
every  child  with  an  acute  cold  must  be  considered  to  be  a  pos- 
sible case  of  measles,  and  an  observational  isolation  in  its  home 
must  be  imposed. 

jManv  cases  of  measles  have  no  physician  in  attendance, 
and  the  health  officer  himself  must  make  inspections  or  employ 
a  public  health  nurse  to  make  them  in  order  to  discover  cases. 
The  sanitary  code  of  New  York  State  requires  householders  and 
school  teachers  to  report  all  cases  with  which  the}-  ha\-e  to  deal. 

The  measures  for  the  suppression  of  an  epidemic  of  measles 
may  be  summarized  as  follows: 

1.  Isolate  every  person  who  is  kno\vn  to  have  the  disease. 

2.  Institute  an  obser\'ational  isolation  of  every  child  that 
has  signs  of  an  acute  cold,  until  the  nature  of  the  sickness  is 
determined. 

3.  Take  the  temperature  of  every  person  that  has  suspicious 
signs.  A  rise  in  temperature  of  1  degree  is  sufficient  to  require 
an  observational  isolation. 

4.  Employ  a  pubKc  health  nurse  to  investigate  suspicious 
cases,  to  visit  the  cases  in  isolation,  and  to  instruct  parents  in 
the  nature  of  the  disease. 

If  an  epidemic  occurs  among  school  children,  closing  the 
school  will  usually  be  both  unnecessary  and  unwise,  for  the 
school  will  aft'ord  an  excellent  opportunity  for  the  obser\'ation 
of  the  children  and  the  detection  of  suspicious  cases.  There 
will  be  no  danger  of  spreading  the  disease  if  those  children  who 
show  evident  signs  are  observed  and  excluded.  The  measures  to 
be  taken  at  school  are: 

1.  Observe  every  pupil  as  soon  as  it  arrives  at  school.  If 
any  child  has  signs  of  a  cold,  take  its  temperature  and  send  it 
home  if  its  temperature  is  1  degree  above  the  normal  This  may 
be  done  by  the  health  officer,  the  school  physician,  the  school 
nurse,  or  the  teacher. 

2.  Investigate  all  absent  children. 

3.  Exclude  every  non-immune  child  in  the  family  in  which 
there  is  a  case. 

If  a  health  officer  has  the  co-operation  of  the  teachers,  med- 
ical examiner,  school  nurse  and  attendance  officer,  and  is  him- 
self active,  he  can  readily  control  an  outbreak  of  measles. 


THE  MINOR   COMMUNICABLE   DISEASES  199 

GERMAN  MEASLES 

Infectiousness. — Little  or  nothing  is  known  about  the  micro- 
organism that  causes  German  measles.  I'he  incubation  period 
is  from  two  to  three  weeks.  The  disease  is  caught  by  contact, 
and  is  rarely  recognized  except  during  epidemics.  Cases  that 
occur  between  epidemics  are  usually  called  plain  measles.  The 
eruption  and  sickness  lasts  about  three  days.  The  preventive 
measure  consists  in  the  isolation  of  the  patient  during  the  con- 
tinuance of  the  rash. 

Recognition. — There  are  few  signs  previous  to  the  appear- 
ance of  the  rash,  and  seldom  a  marked  sickness  following  it. 
The  first  symptom  noticed  is  usually  red  spots  on  the  face,  fol- 
lowed quickly  by  their  appearance  on  the  body.  The  spots 
resemble  those  of  measles,  but  they  are  likely  to  be  somewhat 
darker  in  color.  They  are  usually  abundant,  and  are  often  so 
close  together  that  the  whole  skin  is  red  as  in  scarlet  fever.  A 
diagnostic  sign  of  considerable  value  is  an  enlargement  of  the 
lymph-glands  on  the  back  of  the  neck,  especially  those  im- 
mediately behind  the  ear.  The  recognition  of  the  disease  is 
often  exceedingly  difficult  and  even  impossible,  especially  in  the 
presence  of  an  epidemic  of  another  disease.  Many  cases  of  so- 
called  scarlet  fever  without  desquamation  are  German  measles. 
If  a  supposedly  scarlet  fever  case  has  an  abundant  rash  and  only 
a  slight  sickness,  German  measles  may  be  suspected. 

The  sickness  of  German  measles  is  mild,  and  the  importance 
of  the  disease  lies  in  its  being  confused  with  scarlet  fever  or 
measles.  No  harm  to  public  health  will  come  from  treating 
German  measles  as  scarlet  fever  or  measles,  but  grave  harm  may 
result  from  treating  either  of  them  as  German  measles.  The 
duration  of  the  disease  is  short,  and  in  case  of  doubt,  the  health 
officer  can  require  an  observational  quarantine  of  the  case. 

CHICKENPOX 

Infectiousness. — Chickenpox  is  a  disease  of  childhood  and 
youth.  Some  say  that  it  never  occurs  in  adults,  but  it 
does  occur  now  and  then.  Its  micro-organism  is  unknown, 
but  is  contained  in  the  vesicles  and  dried  scabs  of  the  skin 
eruption  and  in  the  saliva  and  nasal  mucus.  The  disease  is 
readily  communicated  by  contact.  The  incubation  period  is 
from  two  to  three  weeks.  The  preventive  measure  is  the  isola- 
tion of  the  patient  until  all  the  scabs  have  fallen. 

Symptoms. — Chickenpox  rarely  produces  severe  sickness. 
The  first  sign  is  usually  the  appearance  of  red  spots  on  the  fore- 
head. There  may  be  a  slight  fever  just  before  the  rash.  The 
fever  is  usually  mild  during  the  rash,  and  disappears  in  a  day 


200 


THE  HEALTH   OFFICER 


or  two.     The  importance  of  the  disease  lies  in  its  resemblance  to 
smallpox. 

Recognition. — Chickenpox  may  be  recognized  by  the  follow- 
ing points: 

1.  The  duration  of  the  signs  preceding  the  eruption  is  hours, 
while  in  smallpox  it  is  days. 

2.  The  sickness  and  weakness  accompanying  the  onset  are 
slight,  while  in  smallpox  they  are  severe  and  painful. 


Fip.  5. — Chickenpox,  showing  the  distribution  of  the  eruption. 

3.  There  is  a  rapid  development  of  the  individual  spots  of  the 
eruption,  followed  by  drying  and  scabbing  in  less  than  a  week, 
while  in  smallpox  the  development  is  slow. 

4.  A  typical  spot  of  the  rash  is  a  vesicle,  which  is  superficial 
and  soft;  w^hile  in  smallpox  it  is  deep  and  hard,  and  develops 
into  a  pustule. 

5.  The  spots  of  eruption  come  in  crops,  and  all  stages, 
from  spots  of  redness  to  dried  vesicles,  may  be  seen  at  once; 
while  in  smallpox  the  individual  spots  of  the  eruption  are  uni- 
form in  the  time  and  stage  of  their  development. 


THE   MINOR   COMMUNICABLE  DISEASES  201 

6.  The  distribution  of  the  eruption  is  the  most  valuable 
diagnostic  sign.  It  is  most  marked  on  the  trunk,  and  least  on 
the  face,  hands,  and  feet;  while  in  smallpox  it  is  most  marked  on 
the  face  and  extremities,  and  least  on  the  trunk.  It  is  sometimes 
stated  that  chickenpox  never  produces  an  eruption  on  the 
palms  and  soles,  but  eruptive  spots  do  sometimes  appear  in  these 
locations  in  chickenpox  as  well  as  in  smallpox.  Eruptive  spots 
on  the  hard  palate  are  common  in  chickenpox  and  infrequent  in 
smallpox. 

When  a  health  officer  is  called  to  a  case  of  chickenpox  in  a 
grown  person,  it  is  his  duty  to  examine  the  case  thoroughly,  and, 
if  necessary,  on  successive  days.  Inquire  about  the  previous 
vaccination  of  the  patient.  Impose  a  provisional  quarantine 
until  the  diagnosis  can  be  made  beyond  a  doubt.  If  in  doubt 
after  an  observation  of  twenty-four  hours,  request  the  aid  of  an 
expert  diagnostician  from  the  State  Department  of  Health. 

MUMPS 

Infectiousness. — Mumps  is  an  infectious  disease  of  the  sali- 
vary glands,  especially  of  the  parotids.  Its  micro-organism  is 
unknown,  but  is  contained  in  the  saliva.  It  is  not  greatly  con- 
tagious, and  when  an  epidemic  occurs,  it  is  usually  confined  to 
the  children  of  a  single  section  of  a  town  for  a  considerable  period. 
It  usually  produces  only  a  mild  sickness,  and  boards  of  health 
usually  make  little  effort  to  prevent  its  spread.  The  preventive 
measure  is  the  isolation  of  cases  for  two  weeks,  and  for  a  week 
after  the  disappearance  of  the  swelling  of  the  salivary  glands. 

Mumps  frequently  produces  an  inflammation  of  the  testicles 
and  ovaries.  Rarely  it  produces  meningitis,  which  is  nearly 
always  mild. 

Recognition. — People  often  confuse  mumps  with  other  con- 
ditions in  which  there  is  a  swelHng  of  the  neck.  Severe  cases 
of  diphtheria,  septic  sore  throat,  scarlet  fever,  and  cervical 
adenitis  are  sometimes  called  mumps,  and  no  physician  is  con- 
sulted. Diseases  have  been  spread,  and  deaths  have  occurred, 
from  a  neglect  to  recognize  the  true  nature  of  the  condition. 
Mumps  is  a  reportable  disease  in  New  York  State,  and  when 
epidemics  occur,  many  cases  of  erroneous  diagnosis  are  found. 
It  is  important  that  every  case  that  is  not  seen  by  a  physician 
shall  be  visited  by  the  health  officer  or  pubHc  health  nurse,  and 
an  accurate  diagnosis  made. 


CIL^PTER  XrX 


SMALLPOX 


Sm.\llpox  is  one  of  the  best  known  and  most  ancient  of 
diseases.  It  was  formerly  as  common  as  measles  now  is.  It 
was  classed  as  a  disease  of  childhood,  and  everybody  expected 
to  have  it,  just  as  they  now  expect  to  have  measles.  Epidemics 
of  the  disease  came  in  waves  as  often  as  there  was  a  sufficient 
supply  of  susceptible  persons.  The  proportion  of  deaths  which 
it  caused  was  greater  than  that  which  tuberculosis  now  causes. 
It  still  threatens  people  of  all  classes  in  every  country. 

Infectiousness. — We  have  little  knowledge  regarding  the 
identity  and  nature  of  the  x-irus  of  smallpox.  The  epithelial 
cells  of  the  spots  of  eruption  are  found  to  contain  small,  round 
masses  called  vaccine  bodies,  which  may  be  the  peculiar  germs 
of  the  disease,  but  nothing  definite  has  yet  been  proved.  The 
virus  is  contained  in  the  pustules  of  the  eruption  on  the  skin, 
and  in  the  natural  excretions  of  the  body.  The  usual  mode  of 
entrance  of  the  virus  into  the  body  is  also  unknown,  except  that 
it  may  be  inoculated  into  the  skin;  but  when  it  is  inoculated,  it 
produces  a  local  pustule  like  that  in  vaccination,  and  no  such 
beginning  lesion  has  ever  been  found  in  the  nose  or  internal 
organs.  The  period  of  incubation  is  about  two  weeks,  but 
varies  from  ten  to  twenty  days.  It  is  possible  for  a  person  to 
transmit  the  disease  before  the  eruption  appears. 

Symptoms. — The  symptoms  of  smallpox  show  a  great  vari- 
ableness. Severe  cases  are  usually  recognized  easily,  but  cases 
which  are  mild  or  irregular  are  puzzling  to  the  best  diagnos- 
ticians. Mild  cases  are  commonly  mistaken  for  chickenpox, 
and  the  severe  forms  with  an  irregular  or  confluent  eruption  are 
often  diagnosed  as  measles,  or  scarlet  fever,  or  typhus  fever. 
The  disease  now  usually  appears  in  a  mild,  irregular  form  which 
is  very  different  from  that  described  by  the  older  physicians. 
A  physician  who  has  not  seen  a  number  of  cases  recently  will 
be  likely  to  find  that  his  previous  experience  will  lead  him 
astray.  A  health  officer  is  not  likely  to  have  an  extensive  oppor- 
tunity to  learn  the  fine  points  of  diagnosis,  and  when  a  sus- 
picious case  occurs,  his  duty  is  to  call  an  expert.  The  diagnostic 
signs  and  symptoms  which  are  most  constantly  in  evidence  are 
as  follows: 


SMALLPOX 


203 


1.  The  onset  is  sudden,  and  the  signs  of  illness  are  severe. 
There  is  a  chill  with  fever,  and  an  intense  headache  and  back- 
ache, and  often  nausea  and  vomiting.  These  symptoms  per- 
sist for  three  or  four  days  before  the  eruption  appears,  decrease 
markedly  when  the  skin  breaks  out,  and  increase  again  when  the 
vesicles  become  pustules.  The  severe  and  lengthy  onset  is  in 
contrast  with  the  mild  and  rapid  onset  of  chickenpox. 

2.  The  eruption  of  smallpox  begins  on  the  forehead  and 
wrists,  and  is  slow  in  developing.     Each  spot  begins  as  a  red 


■J  4      I 

Fig.  6. — Smallpox,  showing  the  distribution  of  the  eruption. 

macule,  and  soon  becomes  a  hard  papule  beneath  the  skin. 
It  becomes  a  vesicle  about  the  fifth  day,  and  a  pustule  about  the 
seventh.  The  pustules  persist  for  about  a  week,  and  dry  up 
during  the  next  week  or  two.  This  is  in  contrast  to  the  devel- 
opment of  the  individual  vesicles  of  chickenpox  within  a  few 
hours. 

The  older  diagnosticians  laid  stress  upon  the  exact  appear- 
ance of  the  individual  spots — their  shotty  feel,  their  red  areola, 
and  their  umbilication — but  these  signs  vary  so  much  that 
they  are  not  conclusive. 


204  THE   HEALTH   OFFICER 

3.  The  eruption  of  smallpox  is  distributed  the  most  pro- 
fusely upon  the  exposed  surfaces  of  the  body — the  face,  hands, 
and  arms — and  is  less  in  amount  on  the  trunk.  This  is  the 
opposite  to  the  distribution  of  the  eruption  in  chickenpox.  The 
distribution  of  the  eruption  is  probably  the  most  reliable  and 
constant  of  all  the  diagnostic  signs  in  smallpox. 

4.  All  the  eruptive  spots  of  smallpox  appear  at  about  the 
same  time,  and  the  vesicles  and  pustules  are  all  of  about  the 
same  age.  There  may  rarely  be  two  or  three  crops  of  papules 
at  the  beginning  of  the  disease,  but  when  the  eruption  is  fully 
developed,  the  spots  will  be  uniform  in  age  and  appearance. 
The  eruption  in  chickenpox  appears  in  successive  crops,  and 
macules,  papules,  and  vesicles  will  be  scattered  over  the  skin  at 
one  time. 

There  is  a  hemorrhagic  type  of  smallpox  in  which  hemorrhages 
occur  in  the  skin  during  the  early  days  of  the  disease  and  pro- 
duce areas  of  a  red  or  purple  color.  These  cases  are  malignant, 
and  resemble  severe  cases  of  scarlet  fever. 

A  common  type  of  smallpox  is  that  in  which  the  disease  is 
extremely  mild,  and  has  only  a  few  spots  of  eruption — in  some 
cases  only  a  dozen.  These  cases  are  usually  overlooked  except 
during  an  epidemic.  The  frequent  existence  of  these  unsus- 
pected cases  is  an  argument  for  the  constant  observance  of 
measures  to  prevent  the  development  of  smallpox. 

A  distinction  is  often  made  between  variola,  or  smallpox 
in  an  unvaccinated  person,  and  varioloid,  or  the  disease  in  one 
who  has  been  vaccinated.  The  distinction  has  no  practical 
value.  Varioloid  means  simply  smallpox  in  which  the  symptoms 
are  mild. 

Another  term  that  was  formerly  used  was  "inoculated  small- 
pox," which  meant  smallpox  that  was  produced  by  the  inten- 
tional inoculation  of  smallpox  virus.  The  inoculation  produces 
a  large  sore  at  the  site  of  the  introduction  of  the  \arus,  and  a 
mild  form  of  the  disease  which  is  identical  with  varioloid. 

Protective  Measures. — The  protective  measures  against 
smallpox  are:  (1)  isolation  and  (2)  vaccination;  and  the  greater 
of  the  two  is  vaccination.  Neither  age,  nor  health,  nor  strength, 
nor  social  state,  nor  cleanliness  will  protect  a  person  who  has 
been  exposed  to  the  disease.  If  all  cases  were  promptly  dis- 
covered and  isolated,  the  disease  would  cease  from  lack  of  fresh 
seed  to  start  a  new  case;  but  this  ideal  has  never  been  reached. 
Cases  of  smallpox  are  constantly  being  missed,  just  as  are  cases 
of  all  other  infectious  diseases.  The  danger  from  smallpox  is 
as  threatening  now  as  it  ever  was.  The  only  reason  that  it  does 
not  now  appear  in  epidemics  is  that  the  departments  of  health 


SMALLPOX 


205 


of  the  great  cities  are  vigilant  and  enforce  vaccination  as  an 
effective  measure  of  prevention  which  is  aimed  directly  at  the 
disease  itself. 

Smallpox  is  one  of  the  most  contagious  of  all  diseases,  and 
a  quarantine  of  every  case  is  required.  The  period  of  quarantine 
is  fourteen  days  after  the  beginning  of  the  eruption,  and  until 
all  the  scabs  have  separated  and  the  scars  healed.  It  is  proper 
to  peel  the  scabs  from  the  palms  and  soles,  for  otherwise  they 
might  remain  in  the  thick  skin  for  weeks. 

Epidemiology. — Smallpox  is  spread  by  contact  with  active 
cases  or  their  fresh  excretions.  When  smallpox  is  suspected, 
the  procedures  which  a  health  officer  is  to  follow  are : 


ARTICLES 


Fig.  7. — Method  of  transmission  of  smallpox. 

1.  Make  a  diagnosis,  calling  in  expert  assistants  from  the 
state  department  of  health  if  necessary. 

2.  If  the  case  is  smallpox,  quarantine  the  sick  person. 

3.  Ascertain  who  have  been  in  contact  with  the  case  since 
the  eruption,  and  whether  or  not  they  have  been  vaccinated 
within  a  year.     Release  those  who  have  been  vaccinated. 

4.  Vaccinate  the  unvaccinated  contacts,  and  allow  them  to 
go  about  as  usual,  provided  they  report  to  the  health  officer  or 
their  family  physician  for  twenty  days,  which  is  the  maximum 
incubation  period  of  smallpox, 

5.  Enforce  a  twenty-day  quarantine  on  the  contacts  who 
refuse  vaccination. 


206  THE  HEALTH    OFFICER 

6.  Pro\ide  a  supply  of  vaccine  that  is  fresh  and  active,  and 
offer  free  vaccination  to  everyone  in  the  community.  The 
charge  for  vaccination  is  a  proper  one  against  the  municipahty. 

7.  Try  to  lind  the  parent  case  from  which  the  patient  caught 
the  disease.  Keep  a  record  of  the  names  and  addresses  of  sus- 
pects in  order  to  follow  up  rumors,  and  verify  the  items  of  in- 
formation which  will  be  freely  offered  to  the  health  officer. 

8.  Secure  the  co-operation  of  the  board  of  health  and  the 
authorization  for  the  details  of  the  management  and  investiga- 
tion of  the  outbreak. 

It  may  be  necessary  to  provide  a  temporary  isolation  place 
for  cases  who  are  in  boarding  houses  and  hotels,  or  who  cannot 
be  properly  isolated  or  given  adequate  care  at  home.  There 
is  less  ground  for  fear  of  contagion  from  an  isolation  hospital 
than  from  a  private  house  that  is  quarantined.  The  limit  of 
air-borne  infection  in  smallpox  is  4  or  5  feet,  and  even  within 
those  distances  the  danger  is  only  from  direct  droplet  infection 
following  coughing.  Still,  a  health  officer  must  expect  a  violent 
opposition  to  an  isolation  place,  but  he  will  have  law  and  reason 
on  his  side  if  his  board  of  health  authorizes  the  hospital. 

Vaccination. — The  production  of  artificial  immunity  was 
often  practised  during  the  18th  century  by  inoculating  persons 
with  smallpox  virus  while  they  were  in  good  health.  This 
method  was  valuable  during  the  times  when  everybody,  expected 
to  have  the  disease,  but  it  had  two  disadvantages:  1,  it  sometimes 
produced  severe  sickness  and  even  death;  and  2,  an  inoculated 
person  could  give  smallpox  as  readily  as  a  person  who  took  the 
disease  in  the  ordinary  way.  It  was  superseded  by  the  present 
method  of  vaccination  after  the  announcement  of  the  discovery 
of  the  protective  value  of  cowpox  inoculation  by  Dr.  Edward 
Jenner,  about  1798.  The  new  method  had  two  great  advantages: 
1,  it  produced  only  a  mild  discomfort;  and  2,  the  inoculated  per- 
son could  not  spread  a  contagion  to  another  person  unless  an 
inoculation  of  matter  from  him  was  made  deliberately. 

The  identity  of  the  germs  of  cowpox  with  those  of  smallpox 
has  been  demonstrated,  for  topical  cowpox  may  be  produced 
by  inoculating  calves  with  the  smallpox  virus.  The  cowpox 
germ  seems  to  be  that  of  smallpox  permanently  modified  by  its 
growth  upon  a  lower  animal.  The  lesions  of  natural  cowpox 
are  sores  about  I  inch  in  diameter  scattered  over  the  teats  and 
udder.  When  a  minute  quantity  of  matter  from  a  co\vpox  sore 
is  inoculated  into  the  skin  of  a  person,  it  produces  a  single  sore 
spot  which  induces  an  almost  complete  immunity  to  smallpox 
and  to  revaccination.  The  quantity  of  antibodies  in  the  blood 
must  usually  be  considerable,  for  vaccine  becomes  inert  when 


SMALLPOX 


207 


it  is  mixed  with  an  equal  quantity  of  blood-serum  from  a  vac- 
cinated calf.  The  immunity  begins  on  the  eighth  or  ninth  day 
after  vaccination,  and  lasts  for  years,  and  often  for  a  lifetime. 
Susceptibility  to  revaccination  returns  sooner  than  suscepti- 
bility to  smallpox.  About  one-half  of  all  persons  may  be  suc- 
cessfully revaccinated  after  an  interval  of  hve  years.  Revac- 
cination after  an  interval  of  twelve  years  is  effective  in  prevent- 
ing epidemics  of  smallpox. 

Method  of  Vaccination. — A  standard  method  of  vaccination 
recommended  by  the  New  York  State  Department  of  Health  is 
as  follows: 


Fig.  8. — A  vaccination  sore  produced  by  the  scratch  method,  showing  the  slight 
effect  on  the  surrounding  skin. 


1.  Cleanse  the  skin  over  the  insertion  of  the  left  deltoid 
muscle  with  alcohol. 

2.  Place  a  small  drop  of  vaccine  on  the  skin. 

3.  Take  a  sterile  needle  and  make  a  single  scratch  \  inch 
long  upon  the  skin  through  the  vaccine. 

4.  Allow  the  vaccine  to  dry. 

5.  Do  not  place  a  shield  or  a  dressing  of  any  kind  over  the 
spot.     The  dried  serum  that  exudes  is  the  best  kind  of  dressing. 

Methods  by  deep  scarification  and  by  cuts  with  a  knife  are 
to  be  condemned,  for  they  produce  open  wounds  which  are  Kable 
to  become  infected. 


208  THE   HEALTH   OFFICER 

Course  of  a  Vaccination. — The  course  of  a  successful  vaccina- 
tion is  as  follows: 

First  to  fourth  day — nothing. 

Fifth  day — slight  redness  along  the  line  of  scratching. 

Sixth  day — a  vesicle  begins  to  appear. 

Seventh  day — the  vesicle  is  well  fonned,  and  a  red  areola  be- 
gins to  surround  it. 

Eighth  and  ninth  days — the  vesicle  is  fully  fonned.  It  is 
about  ^  inch  in  diameter,  and  its  areola  about  \h  inches.  Its 
appearance  tits  the  original  description  of  Jenner  that  it  is  like 
a  "pearl  upon  a  rose  leaf." 

Fourteenth  day — it  has  dried  to  a  brown,  raised  scab,  which 
looks  like  a  button  upon  the  skin. 

Twenty-eighth  day — the  button  has  fallen,  leaving  a  scar. 

The  extent  of  the  scar  depends  upon  the  depth  and  area  of 
the  sore.  A  typical  vaccination  scar  left  by  a  vaccination  sore 
that  has  not  been  contaminated  with  bacteria  will  not  exceed 
I  inch  in  diameter,  and  will  often  be  smaller.  A  scar  1  inch  or 
more  in  diameter  is  usually  evidence  that  the  sore  has  been 
infected. 

Vaccination  in  Immunes. — When  a  person  who  has  recently 
been  vaccinated  is  revaccinated,  a  small  red  papule  appears  at 
the  site  of  the  scratch  mark  within  three  or  four  days.  The 
papule  itches,  but  is  not  sore.  It  disappears  within  a  week,  and 
leaves  no  mark.  The  papule  is  a  manifestation  of  anaphylaxis, 
and  is  produced  by  the  sudden  destruction  of  the  virus  by  the 
antibodies  that  were  produced  by  the  first  vaccination.  The 
appearance  of  the  itching  papule  is  an  evidence  of  iinmunity  to 
vaccination  and  to  smallpox. 

Vaccination  after  Exposure. — x-^ntibodies  begin  to  appear  in 
eight  or  nine  days  after  vaccination.  The  initial  fever  of  small- 
pox begins  on  the  twelfth  to  the  fourteenth  day  after  exposure 
to  infection.  There  is  a  period  of  four  or  five  days  after  infec- 
tion with  smallpox  when  a  vaccination  will  have  a  chance  to 
prevent  smallpox  from  developing;  and  experience  shows  that 
vaccination  will  usually  do  so.  This  fact  constitutes  the  reason 
for  promptly  vaccinating  all  persons  who  have  been  exposed  to 
smallpox.  If  vaccination  is  done  after  an  interval  of  four  or 
five  days  following  exposure  to  smallpox,  but  before  the  begin- 
ning of  the  fever,  it  will  not  pre\'ent  the  development  of  small- 
pox, although  it  will  tend  to  lessen  the  severity  of  the  smallpox. 
A  vaccination  done  after  the  fever  of  smallpox  has  begun  will 
not  be  successful. 

Preparation  of  Vaccine. — The  living  virus  of  vaccine  is  con- 
tained in  the  liquid  matter  and  the  dried  scab  of  a  vaccination 


SMALLPOX  209 

sore.  The  original  vaccinations  were  made  by  the  transfer  of 
the  virus  from  a  cow  to  a  person;  and  then  came  the  methods 
of  transmitting  it  from  one  person  to  another;  and  then  that  of 
from  a  person  to  a  calf  and  back  to  a  person.  The  fresh  virus 
or  scabs  were  first  used,  then  virus  dried  on  bone  splints,  and 
then  virus  preserved  in  a  50  per  cent,  solution  of  glycerin.  The 
present  method  of  production  adopted  by  the  Department  of 
Health  of  New  York  City  is  as  follows : 

1.  Fresh  virus  from  a  healthy  person  is  inoculated  into  a  calf. 

2.  The  calf  virus  is  inoculated  into  a  rabbit. 

3.  The  rabbit  virus  is  transferred  to  a  calf,  and  the  virus 
then  produced  is  that  which  is  distributed  for  vaccinating  human 
beings. 

One  of  the  principal  objects  in  passing  the  virus  through  three 
animals  is  to  exclude  the  possibility  of  the  transfer  of  human 
disease  germs  from  one  person  to  another.  It  might  be  possible 
that  some  of  the  original  germs  would  survive  if  they  were  passed 
through  only  one  animal,  but  hardly  probable  if  they  are  passed 
through  three.  It  is  conceivable  that  some  human  germs  might 
live  in  a  calf,  but  it  is  extreemly  improbable  that  any  human 
germs  would  survive  in  both  a  calf  and  a  rabbit. 

The  calves  on  which  the  commercial  virus  is  grown  are  young 
stock.  They  are  fed  on  milk  alone,  and  are  placed  without 
bedding  in  concrete  stalls  which  are  kept  as  clean  as  a  surgical 
ward  in  a  hospital.  All  the  operations  on  the  calves  are  done  in 
an  operating-room  with  tile  floors  and  walls,  and  are  performed 
with  the  same  cleanliness  and  asepsis  as  operations  on  human 
beings.  When  a  calf  is  inoculated,  the  skin  on  the  hinder  part 
of  the  abdomen  and  inner  surface  of  the  thighs  is  shaved  and 
cleansed,  and  the  virus  is  introduced  with  the  same  care  that 
would  be  observed  in  operating  on  a  human  being.  The  con- 
tents of  the  vesicles  are  collected  on  about  the  sixth  day.  The 
pulp  is  mixed  with  four  times  its  bulk  of  a  solution  of  50  per 
cent,  glycerin,  49  per  cent,  water,  and  1  per  cent,  carbolic  acid, 
and  is  allowed  to  stand  at  least  five  weeks  while  the  glycerin 
and  carbolic  acid  slowly  kill  the  bacteria  that  may  be  present. 
Bacteriologic  tests  by  plating  and  fermentation  methods  are 
made  frequently  until  no  growth  is  obtained  on  the  media. 
Inoculation  tests  are  also  made  for  tetanus  bacilH  and  strepto- 
cocci. If  all  the  tests  are  satisfactory,  the  vaccine  is  tested  on 
fifteen  unvaccinated  children.  All  must  be  successful  before 
the  vaccine  is  distributed  to  physicians.  Every  knowoi  pre- 
caution is  taken  that  the  vaccine  shall  be  active  and  free  from 
bacteria. 

Vaccine  entirely  free  from  bacteria  may  be  produced  by  in- 

14 


210  THE  HEALTH   OFFICER 

oculating  the  virus  directly  into  the  testes  of  a  rabbit.  The 
virus  consists  of  the  whole  organ  ground  to  a  pulp. 

Vaccine  virus  deteriorates  rapidly  when  it  is  kept  at  a  tem- 
perature of  70°  F.,  but  it  remains  potent  for  months  when  it  is 
kept  at  a  temperature  below  40°  F.  The  failure  of  commercial 
virus  to  produce  a  successful  vaccination  is  often  due  to  its 
being  kept  by  the  druggist  for  too  long  a  time  or  at  too  high  a 
temperature.  The  commercial  vaccine  that  is  made  for  the 
market  is  produced  under  the  supervision  of  the  Federal  Gov- 
ernment, and  by  the  same  methods  that  are  followed  in  New 
York  Cit}'. 

Sources  of  Danger. — Vaccination  produces  an  inflammation 
of  the  skin  and  a  sore  which  is  subject  to  the  same  accidents 
and  dangers  as  any  other  sore.  The  dangers  are  those  of  in- 
fection with  germs  of  human  diseases,  but  they  are  less  than 
those  which  threaten  an  ordinary  cut  linger.  The  possible 
sources  of  danger  are  well  known,  and  may  readily  be  prevented. 

The  first  source  of  danger  is  from  virus  that  is  contaminated 
with  bacteria  and  germs  of  human  diseases.  The  use  of  fresh 
vaccine  that  has  been  produced  by  modern  methods  and  under 
modern  tests  excludes  all  danger  from  the  virus  itself. 

The  second  source  of  danger  is  the  introduction  of  disease 
germs  during  vaccination.  This  may  be  prevented  by  methods 
of  surgical  cleanliness  which  every  physician  is  expected  to  fol- 
low in  his  dealings  with  patients. 

The  third  source  of  danger  is  the  introduction  of  disease 
germs  into  the  sore  after  it  has  developed.  The  pre\'ention  of 
this  danger  depends  upon  the  persons  who  are  vaccinated  or 
upon  those  who  care  for  them.  A  child  who  is  allowed  to  play 
roughly  in  dirty  places  is  likely  to  injure  the  sore  accidentally, 
and  to  introduce  dirt  into  it.  Most  of  the  accidents  following 
vaccination  happen  in  that  way.  For  example,  a  child  who 
had  tetanus  following  vaccination  had  been  allowed  to  play  con- 
stantly in  a  pile  of  soil  that  was  thrown  up  during  the  construc- 
tion of  a  street  sewer,  although  street  dirt  is  usually  contaminated 
with  tetanus  germs.  No  method  of  the  after-care  of  vaccination 
is  fool-proof,  but  the  danger  is  very  slight  if  the  sore  receives 
ordinary  care. 

Opposition  to  Vaccination. — The  rarity  of  cases  of  smallpox 
leads  many  persons  to  regard  vaccination  as  an  unnecessary 
and  e\-en  dangerous  procedure.  One  of  their  arguments  is  that 
vaccination  is  unsound  in  principle.  They  argue  that  it  is 
wTong  to  introduce  matter  from  a  loathesome  sore  into  the 
body.  They  seem  to  believe  that  the  matter  remains  in  the 
body.    Not  only  does  it  not  remain  in  the  body,  but  it  excites 


SMALLPOX  211 

the  body  to  produce  defensive  substances  which  destroy  it  and 
then  remain  in  the  blood  ready  to  destroy  any  other  collection 
of  similar  matter  that  may  enter  the  body.  A  very  few  persons 
have  the  defensive  substances  in  their  blood  from  birth,  but 
most  persons  will  not  produce  it  until  their  bodies  are  in  actual 
contact  with  the  virus.  Those  who  oppose  vaccination  are  like 
parents  who  are  unwilling  that  their  children  should  go  into 
the  water  until  they  know  how  to  swim.  A  very  few  children 
are  able  to  swim  at  the  first  trial,  but  most  children  have  to  learn 
to  swim  by  subjecting  themselves  to  the  discomforts  of  the  water. 
In  the  same  manner,  the  body  learns  to  produce  defensive  sub- 
stances against  smallpox  by  its  experience  with  the  harmless 
virus  of  vaccination. 

A  second  argument  against  vaccination  is  that  a  vaccination 
sore  produces  more  discomfort  and  sickness  than  smallpox  it- 
self. Those  who  give  this  argument  believe  that  smallpox  has 
changed  its  character  and  has  ceased  to  be  a  deadly  disease. 
They  also  believe  that  vaccination  necessarily  produces  great 
discomfort  and  sickness.  It  is  true  that  most  cases  of  smallpox 
are  now  mild,  but  the  virulence  of  all  contagious  diseases  varies 
from  year  to  year.  Scarlet  fever  now  exists  in  a  mild  form, 
while  infantile  paralysis  is  ten  times  more  fatal  than  ever  before. 
The  modern  vaccination  produces  only  a  slight  discomfort,  and 
its  dangers  can  be  readily  foreseen  and  prevented. 

A  third  argument  against  vaccination  is  that  it  may  transmit 
diseases  such  as  septicemia,  tetanus,  tuberculosis,  and  syphihs. 
The  precautions  which  are  now  taken  insure  the  purity  of  the 
virus,  and  ordinary  surgical  cleanHness  prevents  the  introduc- 
tion of  germs  during  the  operation. 

A  fourth  argument  against  vaccination  is  that  it  is  unneces- 
sary since  smallpox  has  nearly  disappeared  from  civiKzed  lands. 
This  same  kind  of  argument  would  hold  against  the  purchase 
of  an  apparatus  for  fighting  fire,  and  against  making  buildings 
fireproof.  Absence  of  fire  for  a  year,  or  for  ten  years,  does  not 
mean  an  absence  of  danger  that  a  fire  will  occur.  Experience 
shows  that  smallpox  is  Hkely  to  break  out  in  an  unvaccinated 
comanunity  just  as  fires  occur  among  wooden  buildings. 


CHAPTER  XX 


DIPHTHERIA 


'  Nature  of  Diphtheria. — Diphtheria  is  one  of  the  most  com- 
mon tiiseases  with  which  a  health  officer  has  to  deal.  Its  nature 
and  the  manner  in  which  it  spreads  have  been  ascertained  with 
a  considerable  degree  of  exactness.  The  methods  of  its  pre- 
vention and  control  have  been  standardized  and  can  readily  be 
applied  by  every  health  officer  and  physician. 

Diphtheria  is  a  disease  of  the  throat,  nose,  or  trachea,  caused 
by  a  gemi  called  the  Klebs-Loffler  bacillus.  The  bacilli  produce 
a  white  or  yellow  membrane  which  is  usually  plainly  visible 
when  it  is  on  the  tonsils  and  surrounding  parts,  but  it  may  be 
so  thin  that  it  can  scarcely  be  noticeable.  If  it  is  in  the  nose  or 
trachea,  its  location  prevents  it  from  being  seen.  Other  bac- 
teria often  grow  with  the  diphtheria  bacilli  and  produce  swellings 
and  abscesses.  The  disease  will  usually  develop  within  a  few 
hours  or  days  after  infection  with  the  germs. 

The  danger  in  diphtheria  is  from  two  causes:  1,  a  poisoning 
by  the  toxins  of  the  baciUi;  and  2,  an  obstruction  of  the  trachea 
interfering  with  breathing.  The  toxin  of  diphtheria  produces  a 
rapid  and  general  poisoning  of  the  cells  of  the  body,  and  espe- 
cially those  of  the  heart.  A  poisoning  of  the  nerves  is  also 
likely  to  occur,  leading  to  paralysis,  especially  of  the  motor 
nerves  of  the  throat. 

Recognition  of  Diphtheria. — Diphtheria  may  be  suspected  if 
any  throat  trouble  is  present;  or  if  the  breathing  is  obstructed; 
or  if  there  are  signs  of  a  paralysis  of  the  throat,  such  as  difficulty 
in  swallowing.  There  is  usually  a  fe\-er  and  a  great  weakness 
of  the  body.  There  may  be  a  sore  throat,  although  the  worst 
cases  are  often  painless,  owing  to  the  paralysis  of  the  ner\'es. 
If  there  is  no  soreness,  there  may  be  no  special  signs  to  call 
attention  to  the  throat,  and  the  disease  may  reach  a  dangerous 
stage  before  its  existence  is  suspected. 

There  are  two  methods  of  recognizing  diphtheria:  1,  by  look- 
ing into  the  throat  for  a  membrane;  and  2,  by  taking  a  culture 
from  the  throat  or  nose. 

When  a  doctor  is  called  to  see  a  sick  child,  the  invariable 
rule  ought  to  be  that  he  look  into  the  child's  throat.  Doctors 
sometimes  yield  to  the  desires  of  the  child  or  of  its  parents  and 
do  not  examine  the  throat,  and  thus  they  often  fail  to  recognize 


DIPHTHERIA 


213 


diphtheria  in  its  early  stages  while  it  may  readily  be  cured. 
The  presence  of  spots  or  a  membrane  on  the  tonsils  or  other 
situation  in  the  back  part  of  the  throat  is  strongly  suggestive  of 
diphtheria,  but  it  is  not  always  a  proof  of  the  disease,  for  they 
may  be  due  to  other  causes,  such  as  simple  tonsillitis,  or  septic 
sore  throat,  or  Vincent's  angina. 

Cultures. — The  only  sure  indication  of  diphtheria  is  to  find 
diphtheria  bacilli  in  a  culture  from  the  throat  or  nose.  The 
New  York  State  Department  of  Health  requires  a  culture  to  be 
taken  of  every  case  having  a  membrane  in  the  throat,  whether 


Fig.  9^ — Method  of  holding  a  struggling  child  in  order  to  obtain  a  throat  culture. 


the  membrane  is  characteristic  or  is  only  suspicious.  The 
department  furnishes  every  health  officer  with  outfits  for  taking 
the  cultures,  and  examines  the  cultures  without  charge.  The 
examination  of  cultures  sometimes  shows  the  absence  of  diph- 
theria from  throats  in  which  a  membrane  is  present,  and  often 
reveals  the  germs  when  no  membrane  can  be  seen. 

How  to  Take  a  Culture. — The  outfit  for  taking  a  diphtheria 
culture  consists  of  (1)  a  sterile  cotton  swab,  and  (2)  a  culture- 
tube  containing  a  culture-medium  of  coagulated  blood-serum. 

When  the  throat  is  to  be  examined,  or  a  culture  is  to  be  taken, 


214  THE  HEALTH   OFFICER 

arrange  a  light  to  shine  into  the  throat.  Have  the  child  open 
its  mouth  wide.  Depress  its  tongue  with  the  handle  of  a  spoon 
or  with  a  tongue-depressor,  in  order  to  get  a  good  view  of  the 
tonsils  and  back  part  of  the  throat. 

If  a  child  refuses  to  remain  still  or  to  open  his  mouth,  have 
a  strong  person  hold  him  in  the  following  manner:  Seat  the 
child  on  the  left  knee  of  the  person  holding  him,  and  throw 
the  right  leg  over  the  child's  legs.  Clasp  the  left  hand  around 
the  child's  forehead  and  hold  its  head  tirmly  against  the  shoul- 
der. Hold  the  child's  hands  lirmly  with  the  right  hand.  The 
child  can  now  be  held  finnly  in  position.  If  the  child  will  not 
open  its  mouth,  press  a  spoon  handle  between  the  teeth  and  into 
the  back  of  the  throat.  This  will  cause  a  retching  or  gagging. 
During  the  act  the  chlid  will  hold  its  mouth  open.  The  procedure 
causes  no  pain  or  discomfort,  and  is  a  far  more  kind  procedure 
than  prolonging  the  child's  baseless  fears  of  an  examination. 

The  method  of  making  a  culture  from  the  throat  is  as  follows: 

1.  Depress  the  tongue  with  the  left  hand. 

2.  Hold  the  swab  in  the  right  hand  and  rub  it  over  the 
membrane,  or  tonsils,  or  back  of  the  throat. 

3.  Hold  the  culture-tube  in  the  left  hand,  and  remove  the 
plug  from  its  mouth  by  grasping  it  with  the  little  finger  of  the 
right  hand. 

4.  Rub  the  swab  lightly  over  the  surface  of  the  culture- 
medium  and  replace  the  plug. 

5.  Throw  the  swab  into  a  fire,  or  replace  it  in  its  container, 
if  one  is  provided. 

6.  Place  the  tube  in  the  container  which  is  provided  with  the 
outfit  and  mail  it  to  the  laboratory. 

In  order  to  take  a  culture  from  the  nose,  pass  the  swab  into 
a  nostril  horizontally  backward  along  the  nasal  floor  until  it 
touches  the  posterior  wall  of  the  phar}Tix,  and  at  once  withdraw 
it.  Rotating  the  handle  of  the  swab  between  the  thumb  and 
finger  will  aid  in  its  passage. 

Do  not  use  a  culture-tube  that  is  dry  or  moldy.  Be  sure 
that  the  swab  is  rubbed  over  the  membrane.  Do  not  allow  the 
swab  to  touch  anything  except  the  throat  and  the  culture-tube. 
The  danger  is  (1)  that  it  may  pick  up  the  ordinary  bacteria  of 
the  mouth,  and  (2)  it  may  contaminate  other  objects  with 
diphtheria  germs. 

Do  not  mail  the  culture-tube  in  any  other  container  than  the 
one  provided  by  the  laboratory,  for  the  postal  laws  forbid  the 
use  of  any  other  container. 

Make  out  a  report  of  the  case  on  a  blank  that  accompanies 
each  outfit,  and  send  it  to  the  laboratory  with  the  specimen. 


DIPHTHERIA 


215 


If  the  case  appears  to  be  diphtheria,  do  not  wait  for  a  report, 
but  begin  treatment  at  once. 

When  the  culture  reaches  the  laboratory,  it  will  be  placed 
in  an  incubator.  The  germs  grow  more  rapidly  than  most 
other  kinds  of  bacteria,  and  in  from  twelve  to  twenty-four  hours 
the  growth  will  be  sufficient  for  an  examination  and  report. 
This  r-apidity  of  growth  causes  diphtheria  germs  to  outgrow 
other  bacteria,  and  the  growth  that  is  obtained  in  positive  cases 
is  usually  a  pure  culture  of  diphtheria  germs. 

The  diseases  for  which  diphtheria  is  often  mistaken  are 
tonsillitis,   septic  sore  throat,  and  Vincent's  angina.     No  one 


CARRIER 


TOILET  ARTICLES  &  DISHES 


MILK 


Fig.  10. — Method  of  transmission  of  diphtheria. 


can  always  tell  these  three  diseases  from  diphtheria  without  a 
culture. 

Manner  of  Spread. — Almost  the  only  source  of  diphtheria 
germs  is  the  human  throat.  Very  rarely  diphtheria  germs  may 
be  found  growing  in  sores  on  the  skin  or  in  the  eye.  It  is  barely 
possible  that  a  cat  or  other  domestic  animal  may  have  the 
disease. 

Most  cases  of  diphtheria  are  acquired  by  contact  with  a 
person  who  has  diphtheria  germs  in  his  throat,  or  with  some- 
thing which  has  recently  touched  his  mouth  or  nose,  such  as  a 


216  THE  HEALTH   OFFICER 

drinking-cup  or  a  towel.  Some  cases  are  acquired  from  milk 
which  contains  diphtheria  germs,  but  the  germs  themselves 
come  from  an  infected  person  who  handles  the  milk.  If  milk 
is  the  cause  of  diphtheria,  there  is  likely  to  be  a  number  of  cases 
distributed  along  a  milk  route.  A  few  diphtheria  gemis,  in- 
troduced into  milk  by  a  carrier,  may  multiply  to  a  sufficient 
number  to  infect  susceptible  persons  all  along  a  delivery  route. 

The  germs  of  diphtheria  are  not  long  lived,  but  soon  die 
when  they  are  exposed  to  the  light  or  to  drying,  or  to  the  action 
of  bacteria  of  fermentation  and  putrefaction,  as  they  are  in  ordi- 
nary cesspools.  Diphtheria  is  not  spread  by  sewer-gas,  as  was 
formerly  taught. 

Isolation. — When  a  case  of  diphtheria  is  reported,  the  first 
duty  of  a  health  officer  is  to  prevent  the  disease  from  spreading 
to  other  persons.  He  will  therefore,  1,  isolate  the  case;  2,  place 
a  placard  on  the  house  stating  that  there  is  a  contagious  disease 
in  the  house;  and  3,  give  the  people  in  the  house  definite  instruc- 
tions regarding  (a)  the  method  of  maintaining  the  isolation, 
[b)  the  care  of  clothing,  dishes,  and  other  things  in  the  sick 
room,  and  (c)  the  disposal  of  all  excretions  from  the  sick  per- 
sons. He  will  also  give  the  parent  or  nurse  a  copy  of  a  pamphlet 
on  diphtheria  such  as  that  suppUed  by  the  New  York  State 
Department  of  Health. 

Measures  of  isolation  and  quarantine  are  not  strictly  legal 
until  the  existence  of  diphtheria  has  been  proved  beyond  dispute. 
Yet  it  would  be  wrong  to  delay  isolation  or  quarantine  until  a 
report  of  a  culture  can  be  received.  A  health  officer  will  be 
upheld  by  the  courts  if  he  begins  the  isolation  or  quarantine  as 
soon  as  he  has  a  strong  suspicion  that  the  case  is  one  of  diph- 
theria. Even  if  the  case  turns  out  to  be  tonsiUitis  or  septic 
sore  throat,  the  measures  for  its  isolation  are  justifiable,  for  both 
of  these  diseases  are  contagious,  and  are  often  dangerous  to  life. 

People  in  a  community  will  sometimes  disregard  a  quaran- 
tine from  ignorance,  or  prejudice,  or  crowded  conditions.  If 
a  health  officer  cannot  enforce  a  strict  quarantine  during  an 
epidemic,  the  best  thing  for  him  to  do  is  to  get  his  board  of 
health  to  establish  an  isolation  hospital.  If  the  board  does 
this,  it  must  also  authorize  the  health  officer  to  remove  to 
the  hospital  every  case  that  cannot  be  properly  isolated  or 
treated  at  home.  If  this  authority  is  not  given,  the  health 
officer  cannot  legally  compel  a  person  to  go  to  the  hospital. 

The  end  of  a  period  of  isolation  in  diphtheria  is  determined 
by  the  absence  of  germs  from  the  throat.  A  throat  may  appear 
to  be  well,  and  yet  it  may  continue  to  harbor  virulent  germs  for 
days  and  weeks.     The  rule  is  not  to  release  a  person  from 


DIPHTHERIA  217 

isolation  until  at  least  two  negative  cultures  have  been  obtained 
on  successive  days.  If  the  germs  persist  after  four  weeks,  it 
will  be  proper  for  a  health  officer  to  ask  that  a  virulence  test 
be  made,  and  if  the  germs  are  proved  to  be  non-virulent,  he  may 
dismiss  the  case. 

The  health  officer  must  give  instructions  for  the  disposal  of 
excretions,  the  cleanliness  of  the  persons  in  attendance,  and  of 
the  utensils  in  use  in  the  rooms. 

It  is  the  duty  of  a  health  officer  to  assist  in  treating  cases  of 
diphtheria,  even  though  the  burden  and  responsibility  of  the 
treatment  is  on  the  family  physicians.  Every  health  officer 
ought  to  prepare  himself  to  be  a  specialist  in  diphtheria,  and 
to  place  his  services  freely  at  the  disposal  of  the  physicians. 

It  is  essential  that  every  person  who  has  diphtheria  should 
go  to  bed  and  stay  there  as  long  as  a  membrane  can  be  seen  in 
the  throat.  The  toxin  of  diphtheria  is  a  poison  to  the  heart, 
and  sudden  death  may  occur  after  an  exertion  which  would 
ordinarily  be  harmless. 

Difl&cult  breathing  in  diphtheria  usually  signifies  that  the 
membrane  is  obstructing  the  trachea.  This  condition  is  now 
rarely  seen,  owing  to  the  general  use  of  antitoxin.  But  a  health 
officer  may  encounter  it  at  any  time  in  neglected  cases.  The 
saving  of  life  may  then  depend  on  relieving  the  obstruction 
promptly.  A  former  remedy  for  this  condition  was  to  perform 
the  operation  of  tracheotomy^  or  opening  the  trachea.  This  is 
a  simple  operation,  and  requires  no  special  skill,  but  the  open- 
ing allows  dust  to  enter  the  lungs,  and  thus  it  often  produces 
pneumonia.  It  is  now  performed  only  in  emergency  cases  when 
nothing  else  can  be  done. 

The  modern  remedy  for  difficult  breathing  in  diphtheria  is 
intubation,  or  the  introduction  of  a  tube  into  the  windpipe. 
Difficult  breathing  is  slow  in  its  development  and  there  is  usu- 
ally abundant  warning  of  impending  danger.  A  set  of  intubat- 
ing instruments  costs  about  $20,  and  their  use  requires  consid- 
erable skill,  but  no  more  than  a  health  officer  can  readily  acquire. 
While  intubation  may  seldom  be  needed,  yet,  when  obstruction 
does  occur,  the  operation  is  life-saving.  No  other  result  in  the 
whole  range  of  medicine  is  so  striking  and  satisfactory  as  the 
quiet  breathing  and  calm  sleep  which  follow  the  intubation  of  a 
suffocating  child.  One  health  officer  in  every  rural  section 
should  be  prepared  to  do  intubations  for  the  other  health 
officers  and  for  physicians. 

Nature  of  Immunity. — Immunity  to  diphtheria  is  due  prin- 
cipally to  the  presence  of  antitoxin  in  the  blood.  About  half  of 
the  persons  who  recover  from  diphtheria  have  no  antitoxin  in 


218  THE  HEALTH   OFFICER 

their  blood.  Their  inimunity  is  bacteriolytic.  Inducing  an 
antitoxin  immunity  is  the  only  practical  means  either  of  curing 
or  of  preventing:  diphtheria  in  an  artificial  manner. 

Giving  Antitoxin. — The  principal  treatment  of  diphtheria 
consists  in  giving  antitoxin.  The  secret  of  success  consists  in 
giving  the  antitoxin  (1)  early  in  the  disease,  and  (2)  in  a  suf- 
ficient amount  to  overcome  the  toxins  that  are  present  in  the 
blood.  The  smallest  quantity  that  is  usually  required  is  3000 
units,  and  the  largest  about  20.000  units. 

Antitoxin  is  given  with  a  hypodennic  syringe,  and  by  one  of 
three  methods:  1,  subcutaneously;  2,  intramuscularly;  and  3, 
intravenously. 

In  the  subcutaneous  method  a  fold  of  skin  is  pinched  up 
between  the  thumb  and  finger.  The  needle  is  thrust  through 
the  skin  and  the  injection  is  made  under  the  skin.  When  the 
antitoxin  is  given  in  this  w'ay,  it  is  slowly  absorbed  into  the 
blood,  and  from  twelve  to  twenty-four  hours  are  required  for 
it  to  enter  the  blood  in  sufficient  quantity  to  produce  its 
effects. 

In  the  intramuscular  method  the  needle  is  thrust  at  right 
angles  to  the  skin  into  a  muscular  part  of  the  body.  Antitoxin 
given  in  this  way  reaches  the  blood  in  large  amounts  within 
three  or  four  hours. 

In  the  intravenous  method  the  needle  is  thrust  into  a  vein  by 
the  following  method : 

Tie  a  bandage  around  the  upper  arm  in  order  to  obstruct 
the  flow  of  blood  and  distend  a  vein  at  the  bend  of  the  elbow. 
Paint  the  skin  with  tincture  of  iodin  in  order  to  sterilize  it.  Hold 
the  needle  parallel  with  the  skin  with  the  slanting  side  of  its  tip 
upw^ard.  Thrust  it  into  the  vein,  remove  the  bandage,  and 
inject  the  antitoxin  slowly.  When  the  antitoxin  is  given  in 
this  way,  it  begins  to  produce  its  effects  within  an  hour  or 
two. 

Timid  physicians  often  give  3000  units  subcutaneously  and 
wait  twenty-four  hours,  and  if  there  is  no  improvement,  they 
repeat  the  dose.  Giving  antito.xin  in  this  way  is  like  pouring  a 
little  water  on  a  big  fire.  The  proper  plan  is  to  give  a  suf- 
ficient quantity  in  one  dose  and  then  stop  giving  it.  When  the 
blood  has  sufficient  antitoxin  to  neutralize  the  to.xin  there  is 
no  advantage  in  giving  more. 

The  doses  of  antitoxin  by  the  single  dose  method  and  the 
methods  of  giving  it  that  are  advised  by  the  New  York  Depart- 
ment of  Health  are  as  follows: 


DIPHTHERIA 


219 


Mild. 

Moderate. 

Severe. 

Malignant. 

Cases.                           Units. 

Units. 

Units. 

Units. 

Infant,  10-30  lbs.  (under 

2  years) 2000-3000 

3000-  5,000 

5,000-10,000 

10,000 

Child,  30-90  lbs.  (under 

15  years) 3000-4000 

4000-10,000 

10,000-15,000 

15,000-20,000 

Adult,  90  lbs.  and  over .  .  .  3000-5000 

5000-10,000 

10,000-20,000 

20,000-40,000 

Method  of  Administration:  Subcuta- 

Intramus- 

Intravenous 

Intravenous. 

neous  or 

cular  or 

or 

intramus- 

subcuta- 

intramuscu- 

cular. 

neous. 

lar. 

The  persons  to  whom  antitoxin  is  dangerous  are  those  who 
suffer  from  asthma,  and  the  only  form  of  asthma  in  which  there 
is  danger  is  that  which  is  produced  when  a  person  goes  near  a 
horse.  This  is  a  rare  form,  but  yet  a  health  officer  ought  to 
ask  if  a  person  has  asthma  before  he  gives  antitoxin  to  him. 
The  bad  effects  come  on  suddenly  within  a  few  seconds  after 
the  injection  and  may  produce  death  almost  instantly.  If  it  is 
necessary  to  give  antitoxin  to  a  person  who  has  attacks  of 
asthma,  give  only  \  c.c.  of  antitoxin  and  wait  an  hour.  If  no 
bad  effects  are  seen,  give  the  remainder  of  the  dose.  The  bad 
effects  are  not  due  to  the  antitoxin,  but  they  are  due  to  the  fact 
that  the  antitoxin  is  contained  in  horse-serum  which  is  a  foreign 
protein.  The  sickness  is  a  manifestation  of  anaphylaxis,  and 
comes  on  in  a  minute  or  two  after  the  injection. 

Antitoxin  sometimes  produces  an  eruption  on  the  skin  con- 
sisting of  red,  raised,  itching  blotches.  These  effects  come  on 
about  a  week  after  the  antitoxin  is  given,  and  are  caused  by  the 
horse-serum  and  not  by  the  antitoxin  itself.  They  are  harmless 
and  disappear  in  a  few  hours  or  days. 

Antitoxin  for  the  Prevention  of  Diphtheria. — Antitoxin  is 
also  given  in  order  to  produce  a  passive  immunity  to  diphtheria 
in  those  who  are  well.  The  dose  for  this  purpose  is  1000  or  1500 
units  given  subcutane6usly.  When  a  case  of  diphtheria  occurs 
in  a  family,  the  rule  is  to  immunize  the  other  members  of  the 
family.  The  immunization  lasts  about  a  month  and  then 
ceases,  for  the  antitoxin  that  is  injected  is  a  foreign  protein  which 
is  soon  thrown  off  from  the  body  and  is  not  reproduced. 

The  Schick  Test. — The  existence  of  antitoxin  in  the  blood 
may  be  determined  by  the  Schick  test.  This  consists  of  inject- 
ing a  quantity  of  diphtheria  toxin  amounting  to  one-fiftieth  of 
a  fatal  dose  for  a  guinea-pig.  This  quantity  of  toxin  is  diluted 
so  that  it  is  contained  in  a  single  drop  of  the  injected  liquid. 
The  injection  is  not  made  under  the  skin,  but  into  it  as  near  the 
surface  as  possible.  A  successful  injection  produces  a  raised 
white  spot  which  has  about  the  size  and  appearance  of  a  swollen 
spot  produced  by  a  mosquito  bite. 


220  THE   HEALTH    OFFICER 

If  antitoxin  is  present  in  the  blood,  it  will  neutralize  the 
injected  toxin,  and  no  efifects  will  be  visible.  But  if  there  is 
no  antitoxin  in  the  blood,  the  toxin  will  poison  the  cells  which 
it  touches,  and  will  produce  a  red  spot  about  the  size  of  a  one 
cent  coin  which  appears  on  the  third  or  fourth  day  after  the  in- 
jection. The  spot  will  not  be  sore,  but  it  will  persist  for  a  few 
days  and  will  then  disappear,  leaving  a  transient  pigmentation. 
^  A  positive  Schick  test,  therefore,  indicates  an  absence  of  anti- 
•^  toxin  and  a  susceptibility  to  diphtheria.  A  negative  Schick 
test  indicates  the  presence  of  antito.xin  and  an  immunity  to  diph- 
theria. 

About  two-thirds  of  all  persons  will  give  a  negative  Schick 
reaction,  indicating  that  they  naturally  have  antitoxin  in  their 
blood,  and  are  immune  to  diphtheria.  One-twentieth  of  a  unit 
of  antitoxin  in  each  cubic  centimeter  of  blood  is  sufficient  for 
protection  against  ordinary  infection  with  diphtheria.  Some 
persons  have  one  or  two  units  of  antitoxin  in  their  blood. 
The  Schick  test  is  of  great  value  in  at  least  three  ways: 

1.  To  detect  those  who  are  immune  and  those  who  are 
susceptible  during  an  epidemic,  especially  in  an  institution. 
There  is  no  advantage  in  giving  antitoxin  to  a  person  who  is 
naturally  immune;  but  a  non-immune  needs  it  after  exposure  to 
diphtheria. 

2.  To  determine  whether  or  not  a  nurse  or  attendant  is 
immune  to  diphtheria.  A  non-immune  person  ought  not  to  be 
allowed  to  care  for  a  diphtheria  case. 

3.  To  determine  immunity  in  experimental  work. 

The  Schick  test  shows  that  1000  units  of  antitoxin  produce 
a  passive  immunity  that  lasts  about  thirty  days.  H  another 
1000  units  are  given,  the  immunity  lasts  for  from  a^en  to  ten 
days  only,  for  the  dose  partly  sensitizes  the  body  to  horse- 
serum,  and  causes  it  to  throw  ofif  the  second  dose  more  quickly 
than  it  did  the  first  one. 

Toxin-antitoxin  Immunity. — An  active  immunity  to  diph- 
theria may  be  induced  by  the  subcutaneous  injection  of  a  mix- 
ture of  toxin  and  antitoxin.  The  standard  mixture  consists  of 
toxin  amounting  to  200  fatal  doses  for  a  guinea-pig,  and  of  an- 
titoxin in  sufficient  amount  to  ovemeutralize  the  toxin.  Three 
injections  are  given  a  week  apart.  A  protective  amount  of  anti- 
toxin appears  in  the  blood  in  about  a  month,  and  persists  for 
years.  Over  90  per  cent,  of  persons  who  have  no  antitoxin  in 
their  blood  will  produce  antitoxin  under  the  stimulus  of  the 
to.xin-antitoxin  mixture. 

The  toxin-antitoxin  method  of  inducing  an  immunity  to 
diphtheria  is  as  valuable  and  practical  as  the  injection  of  vac- 


DIPHTHERIA 


221 


cine  in  the  prevention  of  typhoid  fever.  A  health  officer  will 
use  it  in  producing  permanent  immunity  in  persons  who  show 
a  positive  reaction  to  the  Schick  test. 

Carriers. — Diphtheria  germs  may  grow  in  the  throat  without 
producing  sickness.  They  usually  disappear  from  the  throat 
in  about  two  weeks  after  a  person  recovers  from  diphtheria.  If 
they  persist  for  three  weeks  or  more,  the  person  is  classed  as  a 
carrier. 

Carriers  harbor  the  bacilli  in  situations  to  which  the  blood- 
serum  is  unable  to  penetrate.  The  bacilli  have  been  found 
among  the  epithelial  cells  of  the  tonsils.  They  may  also  grow 
in  the  crypts  of  the  tonsils  and  in  folds  of  the  mucous  membrane 


Fig.  11. — Site  of  diphtheria  germs  in  a  carrier  (X500).  Section  of  a  tonsil 
showing  (a)  a  microscopic  center  of  degenerated  epithelium  packed  with  diphtheria 
bacilli;  b,  normal  epithelium;  c,  tonsillar  tissue. 

of  the  nose.  An  abnormal  condition  of  the  nose  or  throat  can 
be  seen  in  nearly  every  diphtheria  carrier,  and  the  germs  persist 
because  of  the  abnormality. 

A  diphtheria  carrier  can  give  the  disease  to  another  person. 
Most  cases  of  diphtheria  are  caught  from  unrecognized  and  un- 
suspected carriers. 

Virulence  Test. — Diphtheria  bacilli  vary  in  their  virulence 
and  in  their  ability  to  produce  toxin.  If  a  variety  has  only  a 
slight  virulence,  it  cannot  produce  the  disease  in  another  person, 
and  the  carrier  is  harmless. 

A  virulence  test  is  performed  in  the  following  manner: 
A  culture  is  taken  from  a  carrier,  and  the  diphtheria  germs  are 


222  THE   HEALTH    OFFICER 

isolated  from  it  in  a  pure  culture.  A  small  quantity  of  the 
gemis  are  taken  and  killed  and  are  then  injected  into  the  skin 
of  a  normal  guinea-pig.  If  the  bacilli  are  virulent,  they  will 
produce  a  red,  sore  spot  in  three  or  four  days.  The  test  is  like 
the  Schick  test  on  hunian  beings.  Laboratories  of  departments 
of  health  are  now  prepared  to  make  virulence  tests  on  cultures 
from  carriers. 

The  control  of  diphtheria  carriers  is  one  of  the  most  perplex- 
ing and  aggravating  problems  with  which  a  health  officer  has  to 
deal,  for  healthy  carriers  do  not  always  understand  how  they 
endanger  the  health  of  others.  A  carrier  who  takes  reasonable 
precautions  against  transferring  excretions  of  the  nose  and 
throat  to  others  may  safely  go  about  his  work.  Child  carriers 
must  stay  at  home  and  away  from  other  children.  If  a  carrier 
is  reliable,  he  need  not  be  quarantined,  but  if  he  is  unreliable 
and  defiant,  a  health  officer's  duty  is  to  restrain  and  quarantine 
him.  If  a  virulence  test  shows  the  bacilli  to  be  non-virulent,  a 
carrier  may  be  discharged  from  observation. 

Treatment  of  Carriers. — A  healthy  nose  or  throat  will  seldom 
harbor  diphtheria  bacilli.  The  procedures  which  are  of  value 
in  ridding  a  carrier  of  the  bacilli  are  those  which  would  tend  to 
restore  the  throat  to  a  normal  state  if  no  diphtheria  germs  were 
present.  IMost  carriers  have  enlarged  tonsils.  The  removal  of 
the  tonsils  and  adenoids  from  the  throats  of  those  w'ho  have 
them  is  almost  certain  to  rid  a  carrier  of  the  germs.  Nearly 
every  diphtheria  carrier  is  immune.  If  he  were  not  immune  he 
would  have  the  disease  in  an  active  form.  The  administration 
of  antitoxin,  therefore,  has  no  effect  on  the  bacilli  in  their  throats. 

Epidemiology. — When  an  epidemic  of  diphtheria  occurs,  the 
duty  of  the  health  officer  is  to  make  an  investigation  according 
to  the  procedure  outlined  on  page  179.  The  disease  is  spread 
by  contact  of  one  individual  with  another  in  most  cases,  but  an 
epidemic  may  be  due  to  milk.  A  health  officer  can  soon  deter- 
mine whether  or  not  the  epidemic  is  milk-borne,  and  if  it  is,  he 
will  close  the  infected  dairy.  The  principal  duty  of  a  health 
officer  is  to  find  the  positive  cases  and  also  the  carriers  of  diph- 
theria germs.  From  5  to  20  per  cent,  of  all  children  may  be 
found  to  be  carriers  of  diphtheria  germs  while  an  epidemic  is 
going  on.  The  health  officer  will  find  the  carriers  by  means  of 
cultures.  If  the  epidemic  is  prevalent  in  a  restricted  district, 
he  may  have  to  examine  each  person  in  the  district,  but  it  has 
usually  been  found  sufficient  if  he  will  take  cultures  only  from 
those  who  show  a  redness  of  the  throat.  He  will  also  take  cul- 
tures from  school  children  whose  throats  are  red,  but  he  need 
exclude  only  those  who  have  the  germs  present. 


DIPHTHERIA  223 

A  health  officer  must  be  thorough  in  discovering  diphtheria 
cases  and  carriers.  If  he  misses  a  few,  the  epidemic  is  h"kely  to 
continue.  If  an  epidemic  of  a  dozen  cases  breaks  out  in  a  vil- 
lage of  5000  inhabitants,  one  man  might  not  be  able  to  take 
all  the  cultures  which  are  necessary  in  order  to  suppress  the 
epidemic  quickly.  It  is  the  duty  of  the  health  officer  in  such 
an  emergency  to  ask  for  help  from  the  state  department  of 
health.  ' 

Diphtheria  in  Schools. — When  diphtheria  occurs  among 
school  children,  a  health  officer  will  be  expected  to  protect  the 
rest  of  the  children.  The  principal  danger  will  be  from  carriers. 
His  duty  is  to  take  cultures  from  all  children  whose  throats  are 
red  or  sore,  and  to  exclude  all  the  carriers  that  are  found.  It 
is  also  his  duty  to  investigate  all  cases  of  sickness  among  chil- 
dren who  are  absent  from  school.  If  a  health  officer  or  medical 
inspector  will  examine  the  school  children  daily  and  take  cultures 
from  all  suspects  during  an  epidemic,  there  will  be  no  need  to 
close  the  school. 

Diphtheria  in  Institutions. — When  diphtheria  occurs  in  an 
institution,  the  precedure  for  a  health  officer  to  follow  is: 

1.  Take  cultures  from  all  children  who  have  been  associated 
with  the  sick. 

2.  Isolate  the  sick  and  the  carriers. 

3.  Do  the  Schick  test  on  each  inmate  in  order  to  determine 
who  are  immune  and  who  are  not. 

4.  Give  all  those  having  a  positive  Schick  reaction  an  im- 
munizing dose  of  antitoxin. 

5.  Secure  the  removal  of  tonsils  and  adenoids  from  the  car- 
riers. 

Vincent's  angina  is  a  form  of  sore  throat  in  w^hich  there  is 
usually  a  membrane  resembling  that  of  diphtheria.  It  usually 
begins  as  a  small,  whitish  ulcer  upon  the  tonsils  or  other  part  of 
the  throat.  The  ulcer  often  extends  through  the  crypts  of  the 
tonsils  and  produces  an  extensive  loss  of  tissue.  The  disease 
is  to  be  suspected  when  a  deep  ulcer  can  be  seen  in  the  throat  or 
when  the  throat  remains  sore  and  raw  after  what  was  called 
diphtheria.  It  is  caused  by  a  spirochete  which  occurs  in  two 
forms:  (1)  a  large  crescent-shaped  organism  which  stains  heaNily 
and  unevenly;  (2)  a  long,  slender  spirillum  which  stains  faintly. 
A  diagnosis  may  be  made  by  taking  a  specimen  of  membrane 
with  a  swab,  making  a  smear  upon  a  cover-glass,  and  examining 
it  at  once.  Large  numbers  of  both  organisms  will  usually  be 
present  in  a  smear  from  a  positive  case.  A  health  officer  can 
make  a  smear  from  a  suspected  case  and  send  it  to  a  labora- 
tory for  examination. 


224 


THE   HEALTH    OFFICER 


Vincent's  angina  is  not  common,  but  it  sometimes  occurs  in 
epidemics,  and  a  health  officer  must  keep  the  disease  in  mind. 
A  case  must  be  controlled  in  the  same  manner  as  one  of  diph- 
theria. Its  treatment  consists  of  swabbing  the  ulcer  daily  with 
a  20  to  50  per  cent,  solution  of  silver  nitrate,  and  of  painting  the 
throat  frequently  with  weaker  solutions.  A  cure  is  indiSited 
by  a  healing  of  the  ulcer  and  by  the  absence  of  the  organisms 
from  smears. 


CHAPTER  XXI 

SEPTIC  SORE  THROAT 

Simple  Tonsillitis. — Nearly  all  forms  of  sore  throat  and 
tonsillitis  are  communicable  by  contact.  If  one  child  in  a 
family  has  tonsillitis,  other  children  in  the  family  are  likely  to 
catch  it  also.  Sore  throat  and  tonsilhtis  may  be  caused  by  any 
one  of  a  number  of  different  kinds  of  micro-organisms,  but 
especially  by  staphylococci  or  streptococci.  The  diseases  are  of 
great  interest  to  a  health  officer  because  they  may  be  the  only 
evident  signs  of  a  mild  form  of  communicable  disease,  such  as 
diphtheria  or  scarlet  fever,  which  is  usually  severe  and  dangerous. 
The  proper  attitude  for  a  health  officer  to  take  is  to  consider 
every  case  of  sore  throat  and  tonsillitis  to  be  catching,  and  to 
request  that  the  afflicted  person  stay  at  home  and  keep  away 
from  other  persons.  An  ordinary  tonsillitis  makes  persons  sick, 
and  if  their  attention  is  called  to  its  infectious  nature,  most 
people  are  willing  to  take  precautions  in  order  to  prevent  the 
spread  of  the  disease. 

The  disease  that  is  called  simple  tonsillitis  usually  affects 
only  those  persons  whose  tonsils  are  enlarged  and  contain  cavi- 
ties or  crypts  in  which  disease  germs  may  lodge  and  grow.  The 
white  points  seen  on  the  tonsils  during  acute  tonsillitis  are  the 
ends  of  plugs  of  offensive  matter  or  thick  pus  which  fills  the 
crypts,  and  which  forms  an  excellent  culture-medium  for  dis- 
ease germs.  This  matter,  and  the  germs  remaining  in  the  crypts 
after  recovery  from  an  attack  of  tonsillitis,  often  constitute  a 
chronic  form  of  infection  which  is  the  source  of  the  germs  or 
toxins  which  cause  rheumatism,  valvular  heart  disease,  and 
arthritis  deformans. 

Septic  Sore  Throat. — A  tonsilhtis  that  is  caused  by  hemolytic 
streptococci  is  especially  infectious,  and  frequently  occurs  in 
epidemics.  It  may  be  spread  to  a  few  individuals  by  con- 
tact, but  the  epidemics  of  the  disease  have  usually  been  milk- 
borne.  The  disease  was  first  noticed  in  the  United  States  in 
Boston  in  1911,  when  over  1000  cases  occurred.  Since  that  year 
many  other  epidemics  have  occurred  in  the  United  States,  and 
the  disease  has  become  one  which  every  health  officer  must  have 
in  mind.  The  disease  is  known  by  the  names  of  septic  sore 
throat,  epidemic  sore  throat,  and  streptococcus  sore  throat, 
each  of  which  is  a  descriptive  term.     The  disease  is  caused  by  a 

IS  225 


226  THE  HEALTH   OFFICER 

special  variety  of  hemolytic  streptococcus  which  has  great 
virulency,  grows  readily  in  milk,  and  may  readily  be  transferred 
from  milk  to  the  human  throat. 

The  signs  of  septic  sore  throat  are  those  of  tonsillitis,  and 
usually  consist  of  a  chill,  sudden  fever,  pains  in  the  head  and 
back,  soreness  of  the  throat  and  glands  of  the  neck,  rapid  pulse, 
and  great  weakness.  A  thin  membrane  may  be  seen  in  the  throat 
in  about  half  of  the  cases,  and  when  it  is  present,  the  disease 
cannot  be  distinguished  from  diphtheria  without  a  throat  cul- 
ture. When  a  culture  is  taken,  it  shows  an  almost  pure  growth 
of  streptococci. 

Septic  sore  throat  may  also  resemble  scarlet  fever.  Epi- 
demics of  the  two  diseases  have  existed  in  the  same  town  at  the 
same  time,  and  cases  could  then  be  distinguished  only  by  the 
absence  of  the  eruption  in  septic  sore  throat  and  its  presence 
in  scarlet  fever.  Streptococci  are  found  in  both  diseases,  and 
both  may  be  milk-borne. 

Septic  sore  throat  is  a  dangerous  disease  and  the  ordinary 
complications  of  streptococcus  infections  are  likely  to  occur  in 
it,  particularly  rheumatism  and  inflammation  of  the  valves  of 
the  heart.  A  considerable  number  of  deaths  may  be  expected  in 
a  large  outbreak. 

Many  cases  of  sickness  that  are  called  ordinary  tonsillitis 
are  due  to  streptococci,  and  are  actual  cases  of  septic  sore  throat 
which  are  caught  by  contact  with  the  infectious  material  from 
the  noses  and  throats  of  other  cases.  The  great  importance  of 
the  disease  is  that  a  dairy  workman  who  has  it  may  discharge 
the  germs  into  milk,  and  may  spread  the  disease  to  dozens  or 
hundreds  of  persons  who  use  the  milk.  Extensive  epidemics  of 
the  disease  have  been  reported  in  recent  years,  and  all  have  been 
milk-borne. 

An  epidemic  of  septic  sore  throat  usually  comprises  a  con- 
siderable number  of  cases  before  its  nature  is  suspected.  It  is 
usually  discovered  by  the  resemblance  of  some  particular  case 
to  diphtheria.  This  case  is  reported  to  the  health  officer,  who 
takes  cultures  and  finds  no  diphtheria  germs,  but  does  find 
streptococci  in  almost  pure  culture.  His  inquiries  then  reveal 
other  cases  of  sore  throat,  and  show  that  most  of  the  affected 
persons  have  used  milk  from  one  source. 

Origin  of  an  Epidemic. — Streptococci  are  frequently  found  in 
the  udders  of  cows,  especially  if  the  udders  arc  inflamed  and 
show  signs  of  disease.  But  the  origin  of  no  epidemic  of  septic 
sore  throat  has  been  definitely  traced  to  a  diseased  cow.  The 
streptococci  of  cow  diseases  seem  to  have  only  a  slight  virulence 
for  human  beings. 


SEPTIC   SORE   THROAT  227 

Wherever  the  origin  of  an  epidemic  of  septic  sore  throat 
has  been  definitely  traced,  it  has  been  found  to  be  a  person  with 
sore  throat  working  in  a  dairy.  The  germs  may  enter  the  milk 
directly  from  the  affected  person,  or  they  may  enter  the  udder 
of  the  cow  from  the  hands  of  the  affected  milker,  and  thus  gain 
access  to  the  milk  indirectly.  The  germs  may  not  produce  a 
soreness  of  the  udder  or  other  evident  sign  of  disease,  for  the 
cow  is  almost  immune  to  human  streptococci.  Yet  the  cow 
may  be  a  carrier  of  virulent  human  germs  and  may  discharge 
them  into  the  milk.  When  an  epidemic  is  traced  to  a  suspected 
dairy,  a  positive  diagnosis  is  made  by  means  of  cultures 
taken  from  the  throats  of  all  the  workmen,  and  of  examinations 
of  individual  samples  of  milk  taken  from  each  quarter  of  each 
cow  in  the  dairy.  The  carrier,  either  human  or  bovine,  or  both, 
will  be  revealed  by  an  almost  pure  culture  of  streptococci. 

Epidemiology. — When  a  health  officer  is  confronted  with  a 
disease  which  may  be  either  septic  sore  throat,  or  scarlet  fever, 
or  simple  tonsillitis,  or  diphtheria,  his  first  duty  is  to  investigate 
all  the  cases,  following  the  method  described  on  page  179.  An 
extensive  epidemic  of  either  of  these  four  diseases  may  be  milk- 
borne,  and  a  health  officer  can  readily  trace  its  source  by  finding 
that  one  milk-supply  is  a  common  element  in  most  of  the  cases. 
The  control  of  the  milk-supply  will  cut  off  the  main  source  of 
the  infection  at  once. 

A  second  duty  of  the  health  officer  is  to  make  an  accurate 
diagnosis  in  every  case,  if  possible;  and  in  doubtful  cases,  to 
isolate  the  cases  until  a  diagnosis  is  made. 

A  third  duty  of  the  health  officer  is  to  take  precautions  for 
the  suppression  of  the  epidemic.     These  measures  are — 

1.  To  exclude  affected  workmen  from  a  dairy. 

2.  To  prohibit  the  sale  of  milk  from  the  infected  dairy  unless 
it  is  pasteurized. 

3.  To  maintain  an  isolation  of  the  known  cases  in  order  to 
prevent  infections  by  contact. 

4.  To  inform  the  pubhc  of  the  existence  and  nature  of  the 
disease,  the  means  of  its  spread,  and  the  measures  for  its  control. 

The  provision  that  will  almost  certainly  prevent  or  suppress 
an  outbreak  of  septic  sore  throat  is  the  pasteurization  of  all  milk. 

The  period  of  exclusion  of  an  infected  workman  from  the 
dairy  is  until  all  signs  of  inflammation  have  disappeared  from 
his  throat,  and  cultures  from  his  throat  no  longer  show  a  pre- 
ponderance of  streptococci. 

When  the  pasteurization  of  an  infected  milk-supply  is  im- 
possible, the  sale  of  raw  milk  may  be  permitted  under  the  follow- 
ing conditions: 


228  THE   HEALTH    OFFICER 

1.  All  workmen  with  sore  throats  shall  be  excluded. 

2.  All  cows  which  show  any  signs  of  inflammation  of  their 
udders  after  an  examination  by  a  veterinarian  shall  be  excluded 
from  the  herd. 

3.  The  pails,  bottles,  brushes,  and  all  other  containers  and 
utensils  shall  be  boiled  for  half  an  hour  in  order  to  destroy  any 
residual  streptococci  that  remain  in  them. 

Duty  of  a  Health  Ofl&cer. — The  duty  of  preventing  an  epi- 
demic of  septic  sore  throat,  and  of  suppressing  an  epidemic  that 
breaks  out,  lies  with  a  health  officer.  The  disease  is  new,  and 
knowledge  of  it  is  not  yet  universal.  Milk  inspections,  the 
scoring  of  dairies,  and  public  conferences  and  lectures  on  milk, 
all  afford  opportunities  to  educate  physicians  and  the  pubUc 
concerning  the  infectiousness  of  colds,  sore  throats,  and  tonsil- 
litis, and  of  the  danger  from  milk  that  is  infected  with  their  germs. 

The  prevention  of  an  epidemic  of  septic  sore  throat  consists 
primarily  in  excluding  all  persons  w^ho  have  the  disease  from 
working  in  a  dairy,  and  in  the  pasteurization  of  milk.  The 
Sanitary  Code  of  New  York  State  requires  that  the  owner  or 
manager  of  a  dairy  shall  report  to  the  health  officer  whene\'er  a 
person  on  the  premises  has  a  sickness  that  is  presumably  com- 
municable, and  has  no  medical  attendant.  The  code  further 
requires  the  exclusion  of  such  persons  from  the  dairy.  A  wise 
interpretation  of  these  provisions  is  that  no  one  with  a  sore 
throat  or  tonsillitis  shall  be  allowed  to  w^ork  in  a  dairy. 


CHAPTER  XXII 

SCARLET  FEVER 

Names. — Scarlet  fever  takes  its  name  from  the  redness  of 
the  skin,  which  appears  early  in  the  sickness.  Many  cases  are 
extremely  mild  and  show  only  a  faint  redness.  Some  doctors 
are  unwilling  to  consider  these  cases  to  be  true  scarlet  fever,  and 
so  they  call  them  scarlatina,  scarlet  rash,  or  roseola,  or  rose  fever, 
or  rose  rash.  Scarlatina  is  the  scientific  name  for  scarlet  fever, 
and  means  any  case  of  scarlet  fever  whether  it  is  mild  or  severe. 
The  other  names  are  used  only  to  deceive  the  pubHc.  They 
mean  scarlet  fever.  If  there  is  doubt  as  to  the  nature  of  the 
disease  in  any  particular  case,  the  patient  is  entitled  to  the 
benefit  of  the  doubt,  and  to  receive  the  care  that  is  due  to  a 
severe  scarlet  fever  case,  for  a  mild  case  may  suddenly  become 
severely  sick. 

Cause. — Scarlet  fever  is  caused  by  an  unidentified  micro- 
organism which  is  readily  transmissible  from  the  sick  to  other 
persons.  Virulent  streptococci  are  always  associated  with  the 
special  organisms  of  the  disease  itself,  and  are  known  to  be  the 
cause  of  many  of  the  severe  conditions  that  sometimes  arise  in 
the  course  of  the  disease.  The  sickness  develops  in  from  three 
to  seven  days  after  exposure  to  the  infection. 

Signs. — Scarlet  fever  begins  suddenly,  usually  with  vomiting 
and  a  fever.  After  about  twenty-four  hours  the  skin  breaks 
out  with  a  red  eruption  beginning  in  the  throat  and  on  the 
chest.  The  eruption  in  the  throat  causes  it  to  be  sore  and  the 
tongue  to  be  red  like  a  strawberry.  The  principal  diagnostic 
marks  are  a  sudden  onset  of  fever  with  vomiting  and  sore 
throat,  followed  in  a  few  hours  by  a  red  eruption  on  the  skin. 
The  scarlet  fever  germs  themselves  may  be  so  virulent  that  they 
produce  death.  They  may  produce  poisons  which  often  cause 
kidney  diseases.  The  severe  complications  of  the  disease  are 
usually  due  to  streptococci  that  grow  with  the  special  germs  of 
scarlet  fever.  The  streptococci  often  produce  earache,  running 
ears,  mastoid  disease,  enlarged  glands,  and  abscesses  of  the  neck. 
They  often  produce  a  membrane  in  the  throat  resembhng  that 
in  diphtheria  and  septic  sore  throat. 

The  eruption  in  scarlet  fever  is  due  to  an  inflammation  of 
the  skin  and  to  microscopic  blisters  which  form  in  the  deeper 

329 


230 


THE   HEALTH   OFFICER 


la}crs  of  the  cpitheluim  and  loosen  the  cells.  When  recovery 
takes  place,  the  loosened  epithelium  peels  off,  or  desquamates,  in 
flakes.  The  peeling  usually  begins  in  from  fourteen  to  twenty- 
one  days  after  the  onset  of  the  sickness.  It  usually  commences 
around  the  roots  of  the  nails  and  extends  over  the  whole  body, 
including  the  palms  and  soles. 

There  is  no  certain  test  for  scarlet  fever  as  there  is  for  diph- 
theria and  other  diseases  whose  germs  are  known.  Many  cases 
are  not  sick  enough  to  have  a  physician,  and  break  out  so  slightly 


TOItET     ARTICLES     Cr  PISHES 


Fisf.  12. — ^Method  of  transmission  of  scarlet  fever. 


that  the  eruption  is  not  noticed.  An  almost  constant  sign  is 
the  desquamation  of  the  skin.  If  a  child  has  a  desquamation 
of  the  skin  two  or  three  weeks  after  it  has  had  a  slight  fever,  it 
may  be  considered  to  have  had  scarlet  fever. 

Method  of  Transmission. — The  living  germs  of  scarlet  fever 
are  found  in  the  excretions  of  the  nose  and  mouth,  but  they  are 
not  found  in  the  skin,  even  during  desquamation.  The  germs 
may  also  be  present  in  discharges  from  the  ear  and  from  ab- 
scesses. The  germs  disappear  when  the  nose  and  throat  become 
normal  and  the  discharges  from  the  ears  and  abscesses  cease, 


SCARLET  PEVER  231 

but  they  are  present  as  long  as  the  discharges  from  the  nose, 
throat,  ears,  or  abscesses  continue.  Many  children  who  have 
had  the  disease  in  an  unrecognized  form  go  among  other  chil- 
dren while  they  are  still  carriers  of  the  germs.  I'hese  carriers 
are  the  cause  of  most  of  the  cases  of  scarlet  fever  that  are  now 
seen. 

Scarlet  fever  is  transmitted  by  contact  with  the  fresh  dis- 
charges of  the  sick  or  with  those  of  a  carrier.  The  germs  pro- 
duce the  disease  in  from  two  to  seven  days  after  they  enter  the 
body.  If  a  child  has  been  exposed  to  the  disease  and  does  not 
become  sick  within  a  week,  it  may  safely  mingle  with  other  chil- 
dren. An  attack  of  the  disease  usually  produces  an  immunity 
that  lasts  for  life. 

Scarlet  fever  may  also  be  milk-borne  by  means  of  germs 
introduced  into  the  milk  by  a  carrier  working  in  a  dairy. 

Duty  of  the  Health  Officer. — Scarlet  fever  is  a  treacherous 
disease,  owing  largely  to  the  presence  of  streptococci  which  are 
ready  to  attack  any  tissue  that  has  been  weakened  by  the  spe- 
cial germ  of  the  scarlet  fever.  Severe  kidney  troubles  or  ear 
diseases  are  likely  to  occur  in  mild  cases  which  are  exposed  to 
the  weather,  overwork,  and  overeating.  The  disease  is  always 
a  source  of  danger,  and  whenever  a  case  occurs,  it  is  the  recog- 
nized duty  of  a  health  officer  to  take  special  precautions  against 
its  spread.  These  precautions  include:  1,  the  discovery  of  cases; 
2,  isolation;  3,  the  disposal  of  excretions;  4,  the  protection  of 
school  children;  5,  the  treatment  of  cases;  6,  the  education  of  the 
public. 

Discovery  of  Cases. — When  a  case  of  scarlet  fever  occurs,  a 
health  officer  knows  that  it  came  from  a  previous  case.  The 
old  case  has  usually  been  a  mild  one  whose  nature  was  not 
suspected.  Children  in  school  are  frequently  discovered  with 
peeling  skins  and  giving  histories  of  a  transient  vomiting  and 
sickness  two  or  three  weeks  previously.  These  are  probably 
missed  scarlet  fever  cases,  and  many  will  be  found  during  an 
epidemic.  They  would  be  discovered  between  epidemics  if  the 
school  and  health  authorities  would  look  for  them. 

The  recognition  of  scarlet  fever  is  often  difficult.  Mild 
cases  are  often  called  simple  tonsillitis.  Scarlet  fever  often  re- 
sembles septic  sore  throat.  Experiences  with  epidemics  of  septic 
sore  throat  seem  to  indicate  that  hemolytic  streptococci  of 
bovine  origin  may  produce  a  disease  in  which  there  is  a  skin 
eruption  like  that  of  scarlet  fever,  but  no  sore  throat. 

A  skin  eruption  like  that  in  scarlet  fever  may  be  produced 
by  drugs,  by  antitoxin,  by  certain  foods,  and  by  burns.  Harm- 
less skin  eruptions,  such  as  unusual  forms  of  hives,  often  resemble 


232  THE  HEALTH   OFFICER 

scarlet  fever.  The  public  will  be  fortunate  if  the  health  officer 
enjoys  the  confidence  of  the  physicians  to  such  an  extent  that 
they  are  willing  to  report  all  doubtful  cases  to  him,  and  to  leave 
the  final  diagnosis  to  his  judgment.  If  the  health  ofiicer  is  in 
doubt,  his  Avisest  course  is  to  inform  the  head  of  the  afflicted 
household  of  his  doubt,  and  to  ask  that  the  suspected  person  be 
kept  at  home  and  away  from  the  rest  of  the  family;  and  to  wait 
two  or  three  weeks  for  the  appearance  of  the  desquamation  of  the 
skin.  If  the  case  is  scarlet  fever,  the  desquamation  will  nearly 
always  appear.  It  may  not  be  an  absolutely  sure  sign  of  scarlet 
fever,  but  it  is  the  best  sign  that  we  have.  Extremely  severe 
cases  of  scarlet  fever  may  resemble  smallpox,  but  the  infective 
nature  of  these  cases  is  evident,  and  the  health  officer  will  order 
all  precautions  to  be  taken  in  all  of  them. 

Isolation. — The  rule  of  New  York  State  is  that  a  case  shall 
be  isolated  for  thirty  days,  or  until  the  nose  and  throat  become 
normal  and  there  are  no  more  abnormal  discharges,  such  as  those 
from  the  ear  and  abscesses.  Peeling  of  the  skin  may  be  dis- 
regarded, but  it  would  be  unwise  to  frighten  the  public  by  allow- 
ing a  child  wdth  evident  peeling  to  mingle  with  others.  There 
is  a  tendency  among  health  w^orkers  to  govern  the  length  of  time 
of  isolation  by  the  state  of  the  diseased  parts  rather  than  by 
any  fixed  or  arbitrary  length  of  time. 

If  a  child  is  properly  isolated  in  one  part  of  a  house,  grown 
persons  living  in  the  same  house  may  safely  continue  at  their 
work,  provided  they  do  not  handle  food  products.  If  they  han- 
dle food,  and  especially  milk,  they  must  not  continue  at  their 
work  unless  they  stay  away  from  the  house. 

Children  who  live  in  a  scarlet  fever  house  must  not  attend 
school  or  mingle  with  other  children.  The  reason  for  this  rule 
is  the  unreliability  of  children  and  the  ever-present  possibility 
that  they  may  come  in  contact  with  the  sick  person. 

Children  who  live  in  a  house  in  which  there  is  scarlet  fever 
may  be  divided  into  two  groups:  1,  the  immunes,  or  those  who 
have  had  the  disease;  and  2,  the  non-immunes,  or  those  who 
have  not  had  it.  If  the  immune  children  leave  the  house,  they 
may  be  released  from  isolation  and  quarantine.  If  the  non- 
immune children  leave  the  house,  they  must  be  kept  under 
observation  for  seven  days,  in  order  to  be  sure  that  they  do  not 
develop  the  disease.  If  then  they  do  not  come  dow^n  wuth  the 
disease,  they  may  be  discharged. 

Disposal  of  Excretions. — The  infective  material  in  scarlet 
fever  is  found  in  the  excretions  of  the  nose  and  throat,  and  of 
the  bowels  and  bladder.  The  excretions  of  the  nose  and  throat 
may  safely  be  received  in  cloths  and  papers  and  burned.    The 


SCARLET  FEVER  233 

excretions  of  the  bowel  and  bladder  may  safely  be  emptied  into 
a  sewer  or  cesspool,  or  they  may  be  buried.  Those  that  remain 
on  the  face  and  hands  of  the  patient  and  on  his  clothing  and  bed- 
clothes and  on  the  floors  and  furniture  of  the  room  may  be 
readily  killed  or  removed  by  the  ordinary  processes  of  washing 
and  cleanHness.  The  germs  are  not  particularly  long  lived,  but 
they  are  readliy  killed  by  the  same  processes  by  which  other 
disease  germs  are  killed.  It  was  formerly  supposed  that  scarlet 
fever  could  be  spread  by  the  germs  that  had  survived  for  months 
on  clothes  and  playthings.  The  existence  of  many  unrecognized 
carriers  would  account  for  the  cases  of  the  disease  which  have 
followed  the  use  of  articles  which  had  been  handled  by  scarlet 
fever  patients  months  previously.  Practical  experience  has 
abundantly  demonstrated  that  ordinary  cleanliness  is  sufficient  to 
render  articles  free  from  scarlet  fever  germs. 

Protection  of  School  Children. — When  scarlet  fever  develops 
among  the  children  of  a  school,  almost  the  only  danger  is  that 
from  mild  and  unrecognized  cases.  Any  child  who  is  likely  to 
spread  the  disease  will  give  signs  which  teachers,  the  school 
nurses,  the  medical  inspectors,  or  the  health  officers  can  readily 
recognize  if  they  are  on  their  guard.  An  inspection  of  the  school 
children  may  reveal  three  suspicious  groups:  1,  children  who 
are  taken  suddenly  with  a  mild  sickness;  2,  children  with  sore 
throats;  and  3,  children  whose  skins  are  peeling.  These  children 
may  possibly  have  the  disease  or  have  had  it  recently.  If  they 
are  discovered  and  excluded,  the  school  may  continue  its  ses- 
sions as  usual. 

Treatment  of  Cases. — Getting  scarlet  fever  cases  well  as 
soon  as  possible  is  essential  in  preventing  the  spread  of  the  dis- 
ease. It  is  the  duty  of  a  health  officer  to  know  the  modern 
methods  of  handling  scarlet  fever,  and  to  place  his  knowledge 
at  the  disposal  of  family  physicians. 

Most  of  the  dangerous  complications  of  scarlet  fever  arise 
from  unclean  conditions  of  the  nose  and  throat.  A  nose  that  is 
stopped  up  and  full  of  mucus  is  a  culture  place  for  streptococci, 
and  a  center  from  which  the  streptococci  spread  to  the  ears  and 
the  tissues  of  the  neck.  An  efficient  method  of  preventing  the 
complications  is  that  of  cleansing  the  nose  with  normal  salt 
solution  (xV  per  cent,  of  salt  in  water).  The  salt  solution  may 
be  sprayed  up  the  nose,  or  it  may  be  poured  into  the  nose  while 
the  child  lies  upon  its  side.  The  solution  may  frighten  a  child 
at  first,  but  the  rehef  and  comfort  after  its  use  is  so  great  that 
children  often  ask  for  it.  If  a  child  who  needs  it  objects  to  its 
use,  the  kindest  procedure  is  to  hold  the  child  firmly  and  apply 
the  solution  thoroughly.     It  is  surprising  how  quickly  and  gladly 


234  THE   HEALTH   OFFICER 

children  in  contagious  disease  hospitals  submit  to  having  their 
noses  cleansed. 

The  blood  of  a  person  who  has  recently  recovered  from  scar- 
let fever  contains  the  antibodies  against  scarlet  fever.  This 
blood  has  been  used  with  excellent  results  in  the  treatment  of 
severe  cases  of  scarlet  fever.  The  method  is  as  follows:  Draw 
from  4  to  8  ounces  of  blood  from  the  donor's  vein  with  a  hypo- 
dermic syringe,  and  inject  it  at  once  deep  into  the  muscles  of 
the  recipient.  The  blood  is  soon  absorbed,  and  the  dangers  of 
an  intra\'enous  injection  are  avoided. 

Education. — The  efficient  control  of  scarlet  fever  depends  on 
the  intelligent  co-operation  of  the  public  with  the  health  officer. 
Some  of  the  modern  methods  of  dealing  with  contagious  dis- 
eases often  seem  lax  to  the  public,  and  the  people  wonder  at  the 
omission  of  old  and  discredited  procedures.  The  people  will 
co-operate  with  the  health  officer  when  they  become  familiar 
with  the  new  methods  of  public  health  work.  Every  case  of 
scarlet  fever  is  a  center  for  educating  the  family  and  the  neigh- 
bors. Every  case  in  a  school  affords  an  opportunity  to  explain 
the  new  methods  of  handling  contagious  diseases.  Nothing  is 
gained  by  secrecy  concerning  contagious  diseases,  but  a  health 
officer  will  promote  his  work  by  taking  advantage  of  every  op- 
portunity to  educate  the  people  in  all  phases  of  preventive  work. 

Epidemiology. — When  a  scarlet  fever  epidemic  breaks  out, 
the  health  officer  or  visiting  epidemiologist  will  make  an  investi- 
gation according  to  the  method  outlined  on  page  J  79.  He  will 
obtain  information  from  all  the  cases,  and  will  analyze  it  to  see 
if  there  has  been  a  common  milk-supply  or  other  common  source 
of  infection.  He  will  also  seek  to  make  an  accurate  diagnosis 
in  every  case.  It  is  possible  to  have  an  epidemic  of  scarlet  fever 
intermingled  with  one  of  septic  sore  throat.  If  both  diseases 
exist  side  by  side,  an  accurate  diagnosis  is  not  necessary,  pro- 
vided all  the  cases  are  subjected  to  the  measures  of  control 
which  are  proper  in  scarlet  fever.  Both  diseases  may  be  spread 
by  personal  contact,  and  by  milk,  and  the  same  measures  of 
investigation  and  control  apply  to  each.  If  an  epidemic  is 
milk-borne,  the  exclusion  of  the  milk  from  market,  or  its  pas- 
teurization, will  control  the  grosser  routes  of  the  spread  of  infec- 
tion; but  an  isolation  of  the  individual  cases  will  be  necessary 
to  prevent  the  development  of  secondary  cases. 

Scarlet  fever  is  usually  spread  by  contact,  and  the  chief 
difficulty  in  its  control  is  to  discover  and  isolate  the  individual 
cases  which  have  not  been  recognized  or  treated,  but  which 
continue  to  mingle  with  other  persons.  The  signs  which  make  a 
health  officer  suspicious  that  a  person  has  had  scarlet  fever  very 


SCARLET  FEVER  235 

recently  are  a  peeling  of  the  skin,  a  redness  of  the  throat,  a 
history  of  vomiting  or  other  signs  of  a  slight  sickness  from  one 
to  three  weeks  previously,  a  history  of  the  exposure  of  the 
suspected  person  to  a  previous  case,  and  the  development  of 
fever  in  a  child  who  has  been  exposed  to  the  suspected  person. 
The  presence  of  any  of  these  signs  during  an  epidemic  is  strongly 
suggestive  of  scarlet  fever.  The  control  of  these  cases  consists 
in  excluding  them  from  contact  with  other  people. 


CHAPTER  XXIII 

ACUTE  RESPIRATORY  DISEASES 

Entity  of  Acute  Respiratory  Diseases. — Nearly  all  acute 
respiratory  diseases  are  infectious  and  communicable.  The 
micro-organisms  of  the  diseases  may  be  classified  as  follows: 

1.  The  pneumococcus  group. 

2.  The  streptococcus  group. 

3.  The  influenza  bacillus. 

4.  The  Micrococcus  catarrhalis. 

5.  The  bacillus  of  whooping-cough. 

6.  Various  other  kinds  of  bacteria,  some  of  which  are  un- 
identified. 

The  micro-organisms  may  involve  either  the  nose,  or  the 
pharynx,  or  the  larynx,  or  the  trachea,  or  the  bronchi,  or  the 
tissues  of  the  lungs,  or  the  pleura;  or  they  may  involve  all  the 
organs.  The  resulting  illness  is  caused  by  a  general  poisoning 
of  the  entire  body  with  the  toxins  of  the  bacteria.  The  sickness 
is  usually  named  according  to  the  local  part  which  gives  the 
prominent  symptoms.  A  common  cold,  coryza,  pharyngitis, 
tonsillitis,  bronchitis,  pneumonia,  and  pleurisy  are  names  given 
the  sickness  according  to  the  anatomic  location  of  the  principal 
site  of  growth  of  the  bacteria,  but  they  do  not  indicate  the  variety 
of  the  bacteria. 

The  severity  of  an  acute  respiratory  infection  depends  on 
two  factors:  1,  the  virulence  of  the  micro-organism,  and  2,  the 
immunity  or  susceptibility  of  the  patient. 

The  degree  of  virulence  of  the  bacteria  varies  within  a  rather 
wide  range;  and  the  symptoms  produced  by  any  of  the  types 
of  bacteria  may  be  only  those  of  a  mild  cold  or  those  of  a  deadly 
illness.  The  pneumococcus  and  streptococcus  groups  are  usu- 
ally far  more  virulent  than  the  other  forms  of  bacteria;  but  the 
sickness  which  they  produce  may  be  extremely  mild.  Bacteria 
from  a  severe  case  of  illness  are  likely  to  produce  the  same  type 
of  disease  when  they  are  inoculated  into  other  persons. 

Immunity  to  acute  respiratory-  diseases  depends  less  upon 
specific  antibodies  and  more  upon  general  health  and  vigor  than 
does  immunity  to  most  other  diseases.  Many  persons  are  car- 
riers of  bacteria  which  do  not  enter  the  tissues  of  the  respiratory 
organs  unless  the  resistance  of  the  body  becomes  lowered  by 
exposure  to  cold  and  dampness,  or  by  excessive  fatigue,  or  by 
dissipation,  or  by  some  other  cause  of  general  weakness. 
236 


ACUTE   RESPIRATORY  DISEASES  237 

PNEUMONIA 

The  general  term  "pneumonia"  is  applied  to  those  condi- 
tions in  which  groups  of  air-cells  of  the  lungs  arc  filled  with 
products  of  inflammation  instead  of  air.  The  physical  signs  and 
appearance  of  the  affected  parts  of  the  lung  are  those  of  solid 
tissues  in  contrast  with  those  of  the  air-filled  tissue  of  a  normal 
lung. 

The  micro-organism  which  produces  pneumonia  is  usually 
either  the  pneumococcus  or  the  streptococcus.  The  influenza 
bacillus  often  causes  the  disease.  Rarely  the  disease  may  be 
caused  by^  other  bacteria,  such  as  the  Micrococcus  catarrhalis 
and  the  typhoid  bacillis. 

Pneumococci  are  divided  into  four  groups  which  differ 
essentially  from  one  another.  The  type  is  recognized  by  means 
of  an  agglutination  test  made  with  the  serum  of  an  animal  that 
has  been  sensitized  with  a  pure  culture  of  that  particular  type. 

Pneumococci  of  Type  1  are  peculiar  in  that  a  curative  serum 
of  considerable  potency  may  be  produced  by  their  introduction 
into  a  lower  animal.  Those  of  Type  2  may  be  used  to  produce 
a  serum  of  very  slight  potency.  Those  of  Type  3  are  surrounded 
with  mucous  envelopes  which  cause  them  to  adhere  in  masses 
in  their  cultures.  Type  4  embraces  a  number  of  other  varieties 
of  pneumococci,  some  of  which  are  extremely  virulent,  while 
others  have  only  slight  virulence.  The  identification  of  the 
individual  strains  of  Type  4  is  not  practically  applied  in  the 
diagnosis  and  treatment  of  cases.  The  number  of  cases  caused 
by  each  type  is  approximately  equal,  although  the  proportions 
vary  widely  in  different  localities  and  epidemics. 

Streptococci. — Pneumonia  may  be  produced  by  two  varieties 
of  streptococci,  the  hemolyticus  and  the  viridans.  The  hemo- 
lytic type  is  the  more  common  and  virulent  of  the  two.  Infec- 
tions with  both  pneumococci  and  streptococci  often  occur. 

Types  of  Pneumonia. — Cases  of  pneumonia  may  be  divided 
in  a  general  way  into  three  types:  1,  the  lobar  type,  in  which 
a  circumscribed  area  is  involved,  while  the  rest  of  the  lung  is 
normal;  2,  bronchopneumonia,  in  which  many  small  patches  of 
lung  are  involved;  and  3,  cases  associated  with  fluid  in  the 
pleural  cavity.  There  is  no  clear-cut  bacteriologic  or  clinical 
distinction  between  the  lobar  type,  bronchopneumonia,  and  a 
severe  form  of  bronchitis.  Cases  which  are  diagnosed  as  bron- 
chitis are  often  bronchopneumonia;  and  a  bronchopneumonia 
often  becomes  a  lobar  pneumonia  by  the  fusion  of  the  separate 
patches  of  affected  tissue.  The  form  produced  by  streptococci 
is -usually  a  bronchopneumonia  at  the  beginning  of  the  disease. 
Inflamed  areas  of  tissue  located  near  the  surface  of  the  lung 


238  THE   HEALTH    OFFICER 

frequently  cause  a  pleurisy  with  the  effusion  of  fluid  or  an  empy- 
ema. The  infective  process  usually  begins  in  the  bronchi  and 
produces  either  a  bronchitis,  a  pneumonia,  or  a  pleurisy  with 
effusion  according  to  the  anatomic  extension  of  the  bacterial 
growth. 

The  diagnosis  of  acute  respiratory  diseases  is  based  on  five 
methods  of  examination,  as  follows: 

1.  Observation  of  the  cHnical  symptoms. 

2.  A  physical  examination  of  the  lungs. 

3.  A  bacteriologic  examination  of  the  inflammatory  products. 

4.  Aspiration  of  the  pleura  with  a  hypodermic  needle. 

5.  An  .v-ray  examination  of  the  lungs. 

It  is  the  duty  of  a  physician  and  health  officer  to  under- 
stand the  nature  of  these  diagnostic  methods,  and  to  apply  them 
to  every  case  if  possible. 

Bacteriologic  Examination.— A  determination  of  the  type  of 
bacteria  present  in  an  acute  respiratory  disease  is  necessary  in 
order  (1)  to  administer  serum  if  pneumococci  of  Type  1  are 
found,  and  (2)  to  treat  the  case  intelligently.  The  specific 
bacteria  are  found  in  the  sputum,  and  in  the  fluid  of  the  pleura 
when  an  effusion  is  present.  Fluid  aspirated  from  the  lung 
tissue  itself  is  likely  to  be  sterile.  A  bacteriologic  examination 
is  of  special  value  when  it  is  done  early  in  the  disease. 

A  specimen  of  sputum  must  be  from  the  lung  itself  or  from 
the  bronchi.  One  from  the  nose  or  throat  may  contain  the 
specific  organisms,  but  it  is  nearly  always  contaminated  with 
mouth  bacteria.  The  manner  of  obtaining  a  specimen  is  as 
follows : 

1.  Sterilize  a  wide-mouthed  bottle  and  its  cover  or  cork  by 
boihng.     A  tubercular  specimen  bottle  may  be  used. 

2.  Brush  the  teeth,  wash  the  mouth,  and  blow  the  nose  of 
the  patient  in  order  to  cleanse  the  parts  from  loose  bacteria 
which  might  contaminate  the  sputum. 

3.  Collect  a  lump  of  expectoration  that  is  raised  by  coughing. 

4.  Close  the  bottle,  label  it,  and  send  it  to  the  laboratory  to 
be  examined  as  soon  as  possible. 

A  standard  method  of  examining  a  specimen  of  sputum  is  as 
follows : 

1.  The  sputum  is  washed  in  normal  salt  solution  in  order  to 
remove  the  mouth  bacteria  from  its  surface. 

2.  About  1  c.c.  of  the  sputum  is  injected  into  the  peritoneal 
cavity  of  a  white  mouse.  The  pneumococci  thrive,  while  the 
other  organisms  tend  to  die. 

3.  The  bacteria  are  removed  from  the  abdomen  of  the  mouse 
after  its  death,  which  usually  occurs  within  thirty-six  hours. 


ACUTE   RESPIRATORY  DISEASES  239 

4.  The  bacteria  are  identified  by  means  of  an  agglutination 
test  made  with  the  serum  of  an  animal  that  has  been  sensitized 
with  a  known  type  of  pneumococci. 

A  more  rapid,  but  somewhat  less  exact,  method  of  recogniz- 
ing the  type  of  pneumococci  is  that  known  as  Avery's,  which  is 
as  follows: 

1.  Wash  the  sputum  in  three  changes  of  normal  salt  solution. 

2.  Emulsify  the  sputum  with  a  syringe  or  mortar. 

3.  Inoculate  the  sputum  into  a  special  culture-medium  con- 
sisting of  1  per  cent,  dextrose  in  broth  and  5  per  cent,  of  rabbit's 
blood. 

4.  Incubate  for  five  hours. 

5.  Centrifuge  at  low  speed  in  order  to  remove  the  red  cor- 
puscles. 

6.  Draw   off  the  fluid.     Add  1  c.c.  of  sterile  bile  to  4  c.c. 
■  of  the  culture  liquid  in  order  to  dissolve  the  pneumococci,  if 

any  are  present.     If  pneumococci  are  present,  the  liquid  will 
become  clear. 

7.  Centrifuge  the  liquid  at  high  speed  in  order  to  remove  any 
solid  particles  from  it. 

8.  Set  up  a  precipitin  test  with  four  tubes.  Put  .0.5  c.c.  of 
the  clear  culture  liquid  into  each  tube. 

To  tube  No.  1  add  0.5  c.c.  of  immune  serum  made  with 

pneumococci.  Type  1. 
To  tube  No.  2  add  0.5  c.c.  of  immune  serum,  Type  2. 
To  tube  No.  3  add  0.5  c.c.  of  immune  serum,  Type  2 

diluted  1  to  10. 
To  tube  No.  4  add  0.5  c.c.  of  immune  serum,  Type  3 

diluted  1  to  5. 

9.  Incubate  one  hour,  and  note  the  results. 

The  presence  of  pneumococci  is  indicated  by  the  dissolving 
and  clearing  action  of  the  bile  on  the  culture  liquid.  Types  1 
or  2  or  3  are  each  indicated  by  the  positive  reaction  to  the 
precipitin  test,  while  Type  4  is  indicated  by  a  negative  reaction. 

Pneumococci  and  streptococci  will  grow  well  on  the  ordi- 
nary diphtheria  culture-tubes  which  are  used  by  health  officers; 
but  the  growth  is  slow,  and  a  diagnosis  requires  two  or  three 
days. 

x-Ray. — There  is  a  great  difference  between  the  density  of 
normal  air-filled  lung  tissue  and  that  of  lung  tissue  whose  air 
cells  are  filled  with  coagulated  substances.  An  a--ray  photo- 
graph will  show  the  extent  of  the  consolidated  areas,  and  will 
reveal  areas  which  are  too  small  to  give  evident  physical  signs. 
It  will  also  show  the  outline  of  the  surface  of  the  lung  and  its 
relation  to  the  chest  walls,  and  will  thereby  reveal  collections  of 


240  THE   HEALTH   OFFICER 

fluid  or  air  in  the  pleural  cavity.  Repeated  a'-ray  examinations 
of  the  chest,  when  they  can  be  made,  are  valuable  and  certain 
means  of  observing  the  extent  and  course  of  a  case  of  pneumonia. 
Aspiration. — The  presence  and  nature  of  fluid  in  the  pleural 
cavity  ma>'  be  determined  by  means  of  a  puncture  and  aspira- 
tion. An  ordinary  pocket  hypodermic  syringe  and  needle  may 
be  used.  The  needle  is  inserted  to  its  full  length  at  the  spot 
where  the  physical  signs  indicate  fluid,  and  gentle  aspiration  is 
made  while  the  needle  is  slowly  withdrawn.  If  fluid  is  present 
at  the  spot,  it  will  be  indicated  by  a  sudden  inrush  into  the 
syringe  when  the  point  of  the  needle  enters  it. 

Fluid  aspirated  from  the  pleural  cavity  will  usually  contain 
the  same  variety  of  bacteria  as  the  sputum;  but  it  may  contain 
streptococci  while  pneumococci  are  recovered  from  the  sputum, 
and  in  that  case  the  presence  of  streptococci  indicates  infection 
with  both  kinds  of  bacteria. 

When  the  fluid  of  an  empyema  complicating  pneumonia  is 
remo\'ed  during  the  early  stage  of  the  disease,  it  is  usually 
clear  except  for  a  cloudiness  caused  by  the  presence  of  bacteria. 
The  fluid  later  may  consist  of  creamy  pus.  The  development  of 
pus  in  severe  cases  may  be  a  favorable  sign  indicating  the  de- 
velopment of  leukocytosis.  The  appearance  of  the  fluid  is  a 
guide  to  treatment.  If  the  fluid  is  not  pus,  the  proper  procedure 
is  aspiration  and  removal  of  the  fluid  as  often  as  any  can  be 
obtained.  Resection  of  a  rib  and  drainage  is  to  be  done  when 
pus  is  fully  developed.  Excellent  results  are  obtained  after 
the  operation  by  treating  the  case  as  an  infected  wound  by  the 
Dakin-Carrel  method  of  irrigation,  examining  the  discharge 
frequently  for  bacteria,  and  closing  the  wound  when  ver}^  few 
bacteria  are  found. 

Serum  Treatment. — Any  variety  of  pneumococci,  when  it  is 
injected  into  a  lower  animal,  may  cause  the  production  of  an 
agglutinin  which  is  of  value  in  diagnosis;  but  only  Type  1  pneu- 
mococci gives  rise  to  sufiicient  antibodies  to  produce  a  serum 
that  is  valuable  for  treatment.  Type  1  serum  is  of  great  value 
in  pneumonia  caused  by  Type  1  pneumococci,  but  it  either  has 
no  value  or  is  harmful  when  the  disease  is  caused  by  other  types 
or  by  streptococci.  It  is  best  not  to  give  the  serum  until  the 
presence  of  pneumococci  and  their  type  can  be  determined. 
The  serum  is  not  an  antitoxin,  but  is  bactericidal,  and  acts  by 
digesting  the  bacteria  in  the  body. 

The  antipneumococcic  serum  is  given  intravenously,  in  doses 
of  from  8  to  12  ounces,  repeated  daily  for  two  or  three  days  if 
necessary.  Its  effect  is  to  bring  on  an  artificial  crisis  with  a  fall 
of  temperature  after  about  twenty-four  hours.     Since  it  is  horse- 


ACUTE   RESPIRATORY  DISEASES  241 

serum,  there  may  be  a  slight  danger  of  producing  anaphylaxis 
with  the  considerable  amount  that  is  required.  In  order  to 
guard  against  anaphylaxis,  the  rule  is  to  give  a  desensitizing 
dose  of  1  c.c,  wait  an  hour,  and  then  give  the  rest. 

Vaccines. — The  immunity  following  an  attack  of  pneumonia 
usually  lasts  for  only  a  short  time,  but  favorable  results  have 
followed  attempts  to  produce  immunity  by  means  of  vaccines 
composed  of  Types  1,2,  and  3  of  pneumococci.  The  use  of  vac- 
cines in  the  treatment  of  pneumonia  is  still  in  the  experimental 
stage. 

Pneumococci  in  Other  Diseases.^ — Pneumococci  are  fre- 
quently found  in  the  blood  of  pneumonia  patients,  and  may  be 
carried  to  other  parts  of  the  body,  where  they  may  lodge  and 
grow.  The  principal  diseases  which  may  be  caused  by  pneu- 
mococci growing  outside  of  the  respiratory  tract  are  meningitis, 
inflammation  of  the  middle  ear,  pericarditis,  and  endocarditis. 
A  pneumococcus  meningitis  is  often  a  complication  of  pneu- 
monia, and  it  may  also  occur  without  signs  of  a  respiratory  dis- 
ease. 

Secondary  Pneumonia.^ — Pneumococci  and  streptococci  fre- 
quently invade  the  lungs  and  produce  pneumonia  during  the 
course  of  other  acute  infectious  diseases,  especially  influenza, 
measles,  and  whooping-cough.  Pneumonia  follows  measles  and 
whooping-cough  in  cities  and  institutions  more  frequently  than 
in  country  districts,  owing  to  the  more  frequent  opportunities  of 
acquiring  a  virulent  infection  under  crowded  conditions. 

WHOOPING-COUGH 

Whooping-CGugh,  or  pertussis,  is  caused  by  an  extremely 
small  germ  called  the  Bacillus  pertussis.  The  germs  closely 
resemble  influenza  bacilli  and  germs  which  are  naturally  found 
in  the  saliva.  The  specific  germs  of  whooping-cough  are  found 
in  the  sputum  and  in  nasal  secretions.  They  are  obtained  in 
cultures  with  difficulty  during  the  first  week  of  the  disease,  but 
readily  at  its  height.  The  blood  of  about  half  of  the  patients 
after  the  first  week  of  the  disease  contains  antibodies  which  mil 
agglutinate  pure  cultures  on  the  germs;  but  the  recognition  of 
the  disease  by  laboratory  methods  is  uncertain,  and  the  prin- 
cipal reliance  in  diagnosis  must  be  placed  on  the  clinical  signs. 

The  germs  of  whooping-cough  grow  in  the  nose,  throat,  and 
respiratory  tubes,  and  produce  an  inflammation  and  the  signs 
of  an  ordinary  cold.  The  incubation  period  is  from  three  to 
eight  days.  The  premonitory  sjonptoms  are  like  those  of  a 
simple  cold,  and  last  about  a  week,  and  then  follows  a  week  or 

i6 


242  THE   HEALTH    OFFICER 

more  of  attacks  of  the  characteristic  coughing.  The  germs  are 
usually  produced  in  the  greatest  abundance  at  the  beginning  of 
the  second  week  of  the  disease,  and  they  usually  disappear  by 
the  end  of  the  third  week,  although  the  inflammation  and  cough 
may  continue  much  longer.  One  of  the  greatest  dangers  con- 
nected with  the  disease  is  a  pneumonia  caused  by  a  secondary 
infection  with  pneumococci,  streptococci,  influenza  bacilli,  and 
other  virulent  micro-organisms. 

Prevention. — Whooping-cough  is  spread  by  contact  and  by 
droplet  infection.  A  person  who  has  the  disease  may  expel  drop- 
lets of  infected  saliva  and  mucus  to  a  distance  of  4  or  5  feet  during 
the  violent  coughing  spells.  The  prevention  of  the  disease  consists 
in  keeping  the  sick  at  least  5  feet  away  from  the  non-immunes. 
There  is  only  a  slight  chance  of  infection  after  a  patient  has  been 
isolated  three  weeks.  The  disease  is  not  extremely  infectious,  and 
less  than  a  third  of  exposed  children  catch  it.  The  complete 
prevention  depends  upon  the  recognition  of  all  cases  before  the 
whooping  stage,  for  the  bacilli  are  expelled  for  days  before  the 
whooping  begins.  When  whooping-cough  is  epidemic,  it  is 
necessary  to  isolate  every  child  with  a  cough  or  apparent  cold  in 
the  head.  One  plan  is  to  allow  an  affected  child  its  freedom 
provided  it  wears  a  yellow  band  as  a  distinctive  sign  of  its 
infection. 

Vaccine  Treatment. — The  injection  of  whooping-cough  germs 
into  lower  animals  causes  them  to  form  protective  antibodies 
against  the  germs.  This  principle  has  been  applied  in  giving 
subcutaneous  injections  of  pure  cultures  of  the  germs  for  the 
prevention  of  whooping-cough  and  for  the  cure  of  the  disease. 
The  vaccine  is  of  great  value  as  a  preventive.  When  a  case 
develops  in  a  family  of  children,  preventive  doses  will  probably 
protect  the  others  from  taking  the  disease.  The  vaccine  is  of 
less  value  after  the  disease  has  begun  to  show  evident  signs,  and 
of  Httle  value  if  its  administration  is  begun  after  severe  symptoms 
have  developed.  The  doses  recommended  by  the  New  York 
State  Department  of  Health  for  prevention  are  three  injections 
three  davs  apart,  containing,  for  children,  500,000,000  bacilli 
for  the  first  dose,  1,000,000,000  for  the  second,  and  2,000,000,000 
for  the  third;  and  for  adults  1,000,000,000,  2,000,000,000,  and 
3,000,000,000.  The  curative  doses  for  children  under  one  year 
are  250,000,000,  500,000,000,  1,000,000,000,  1,500,000,000,  and 
2,000,000,000.  For  patients  over  one  year  the  doses  are  500,- 
000,000,  1,000,000,000,  2,000,000,000,  and  again  2,000,000,000. 
Very  little  soreness  or  other  reaction  is  usually  produced  by  the 
injections. 


ACUTE   RESPIRATORY   DISEASES  243 

INFLUENZA 

Influenza  and  the  grip  are  terms  that  are  applied  loosely  to 
any  form  of  acute  respiratory  disease  that  is  not  evidently  pneu- 
monia, but  they  properly  refer  only  to  the  sickness  that  is  pro- 
duced by  the  influenza  bacillus.  The  bacilli  of  influenza  will 
grow  on  an  ordinary  culture-medium  if  it  contains  hemoglobin. 
They  are  readily  killed  by  drying,  but  may  remain  alive  in  dust 
that  rises  from  freshly  dried  sputum.  They  are  spread  by  the 
contact  of  one  person  with  another,  especially  by  means  of 
droplet  infection. 

The  various  strains  of  influenza  bacilli  diff'er  in  their  vku- 
lence.  Non-virulent  strains  are  wide-spread  and  may  often  be 
found  in  the  throats  of  healthy  persons.  A  virulent  strain 
may  suddenly  arise  and  produce  a  worldwide  epidemic,  as  in 
1889  and  1918. 

Influenza  itself  is  not  a  particularly  dangerous  disease,  but 
it  renders  a  patient  extremely  susceptible  to  pneumonia.  Pneu- 
mococci  and  streptococci  are  likely  to  grow  in  the  lungs  of  those 
who  are  weakened  by  influenza.  Death  from  influenza  is  usu- 
ally caused  by  pneumonia  germs  which  grow  along  with  the 
special  bacteria  of  influenza.  When  an  epidemic  of  influenza 
occurs,  about  one-fifth  of  the  cases  usually  develop  pneumonia, 
and  about  one-fifth  of  the  pneumonia  cases  die. 

The  susceptibility  to  influenza  is  greatest  during  early  adult 
life.  One  factor  which  accounts  for  the  prevalence  of  the  dis- 
ease in  army  camps  is  that  soldiers  are  at  the  most  susceptible 
age  to  catch  influenza. 

A  Cold. — A  common  cold  is  a  name  that  is  applied  to  almost 
any  mild  infection  of  any  part  of  the  respiratory  tract,  especiaUy 
the  nose  or  throat.  Pneumococci  and  streptococci  have  fre- 
quently been  identified  as  the  cause  of  rhinitis,  pharyngitis,  and 
tonsillitis.  Cases  of  pneumonia  are  often  preceded  by  obstinate 
pneumococci  colds,  and  the  organisms  extend  from  the  nose  to 
the  lungs  when  the  general  health  and  resistance  of  the  body 
become  lowered. 

Micrococci  catarrhalis  and  diphtheria  bacilli  are  also  fre- 
quently identified  as  the  cause  of  rhinitis  or  coryza.  The  nasal 
secretions  in  many  mild  cases  of  acute  colds  are  found  to  be  sterile 
within  a  day  or  two  after  their  onset,  and  this  fact  suggests 
that  some  colds  may  be  caused  by  a  filterable  virus  of  mild 
virulency. 

Research  into  the  bacteriology  of  common  colds  is  one  of  the 
greatest  needs  in  public  health.  Two  practical  points  for  a 
health  officer  to  consider  are  (1)  a  common  cold  is  an  infectious 
disease,  and  (2)  affected  persons  are  carriers  of  disease  germs 


244 


THE    HEALTH    OFFICER 


which  are  likely  to  be  virulent  pneumococci,  streptococci,  diph- 
theria bacilli,  or  other  variety  of  virulent  micro-organism. 

A  mild  case  of  whooping-cough  is  often  mistaken  for  a  com- 
mon cold.  A  case  of  measles  resembles  a  common  cold  during 
three  or  four  days  previous  to  the  appearance  of  the  skin  eruption. 

Carriers. — Pneumococci  may  often  be  found  in  the  noses  and 
throats  of  healthy  persons,  but  they  usually  belong  to  Type  4, 
and  are  not  virulent.  Persons  who  come  in  close  contact  with 
a  case  of  pneumonia  frequently  harbor  pneumococci  of  the  same 
type  as  those  of  the  patient,  but  the  organisms  tend  to  disap- 


CARRIER 


TOILET  f^RTlCLES 
O  PISHES 


Fig.  13. — Method  of  transmission  of  acute  respiratory  diseases. 

pear  in  a  few  days  or  weeks  unless  their  supply  is  renewed  by 
repeated  contacts  with  an  actual  case  of  sickness.  Non-virulent 
pneumococci  also  tend  to  disappear,  but  they  are  often  renewed 
by  contact  with  other  persons.  Small  groups  of  persons  who  are 
absent  from  inhabited  regions  for  long  periods,  as,  for  example, 
sailors  on  long  voyages,  and  explorers  in  Arctic  regions,  usually 
become  free  from  pneumococci  and  other  bacteria  of  acute 
respiratory  diseases,  and  do  not  contract  pneumonia  or  colds 
even  when  they  are  exposed  to  cold,  dampness,  fatigue,  and  other 
conditions  which  often  lead  to  respiratory  diseases  in  peopled 
regions.  It  may  be  considered  that  nearly  every  person  in  a  city 
or  village  is  a  carrier  of  pneumococci,  and  that  the  bacilli  may 


ACUTE   RESPIRATORY  DISEASES  245 

invade  the  tissues  and  grow  when  the  general  health  and  vigor 
of  the  body  become  impaired. 

Epidemiology. — Acute  respiratory  diseases,  including  colds, 
influenza,  and  pneumonia,  are  alike,  in  that  they  are  all  highly 
infectious,  and  that  the  infectious  material  is  found  in  the  ex- 
cretions of  the  nose  and  throat.  Each  is  caught  from  an  affected 
person  in  the  same  way  that  measles  or  smallpox  is  caught. 
A  disease  often  goes  through  a  whole  family  when  one  member 
becomes  sick.  Wives  catch  it  from  their  husbands,  parents 
from  their  children,  and  nurses  from  their  patients.  An  acute 
respiratory  disease  may  develop  within  two  days  after  the  bacilli 
are  taken  into  the  body.  That  the  incubation  period  is  short  is 
shown  by: 

1.  The  development  of  the  disease  after  a  known  infection, 
such  as  a  patient  coughing  into  the  doctor's  face  during  a  throat 
examination. 

2.  The  sudden  development  of  many  cases  among  a  group 
of  workmen  or  soldiers  who  are  exposed  to  a  known  case. 

The  principal  things  which  contain  the  bacilli  of  acute  res- 
piratory diseases  are: 

1.  Droplets  expelled  by  violent  expiratory  acts,  such  as 
coughing,  sneezing,  loud  talking,  and  hard  laughter  (page  170). 

2.  Hands  soiled  with  the  excretions  of  the  nose  and  throat. 

3.  Dishes  and  toilet  articles  which  have  been  used  by  patients 
or  carriers. 

4.  Dust  rising  from  freshly  dried  sputum. 

When  these  things  are  controlled,  the  diseases  are  not  likely 
to  spread. 

The  principal  means  by  which  the  germs  of  acute  respiratory 
diseases  are  spread  are : 

1.  Contact  with  a  case. 

2.  Crowding. 

3.  Spitting. 

4.  Poor  ventilation. 

5.  Uncleanhness. 

The  principal  means  of  infection  by  contact  are : 

1.  Droplet  infection. 

2.  Hands  soiled  with  the  excretions  of  the  nose  and  throat 
either  directly  or  through  dust. 

3.  Dishes,  toilet  articles,  and  bed-clothing  soiled  by  the 
patient  or  carrier. 

Crowding  increases  the  chances  of  infection  by — 

1.  Bringing  people  close  together. 

2.  Increasing  the  number  of  sick  persons  and  carriers  with 
whom  each  person  comes  in  contact. 


246  THE   HEALTH    OFFICER 

3.  Increasing  the  amount  of  infectious  material  in  a  given 
space. 

Spitting  on  floors  is  a  common  means  of  spreading  respiratory 
diseases,  for  dust  from  freshly  dried  sputum  may  contain  living 
bacilli.  One's  hands  soiled  with  the  dust  of  dried  sputum  may 
carry  the  bacteria  to  the  nose  or  mouth. 

Poor  ventilation  promotes  the  accumulation  of  infectious 
dust,  especially  in  rooms  in  which  persons  spit  on  the  floors. 
Droplets  of  excretions  from  coughing  or  sneezing  also  become 
dried  and  add  to  the  amount  of  infectious  material  in  the  dust 
of  crowded  meeting  places,  especially  when  ventilation  is  poor. 

Uncleanliness  in  any  respect,  especially  of  the  hands,  pro- 
motes the  chances  of  infection  with  the  bacteria  of  colds  and 
other  acute  respiratory  diseases. 

The  resistance  of  the  body  to  the  growth  of  the  bacteria  of 
respiratory  diseases  depends  on — 

1.  Specific  mimunity. 

2.  Bodily  vigor. 

3.  Fatigue  or  other  temporary  weakness. 

There  are  many  varieties  and  strains  of  the  bacteria  of 
respiratory  diseases,  and  no  one  is  either  susceptible  or  immune 
to  all  of  them.  Probably  one-third  or  one-half  of  the  people 
are  immune  to  the  kind  that  is  the  cause  of  an}-  given  epidemic. 
Bodily  vigor  and  physical  endurance  are  usually  associated  with 
a  high  degree  of  immunity  to  respiratory  diseases;  but  exposure 
to  cold,  fatigue,  dissipation,  or  other  conditions  which  tem- 
porarily weaken  the  body  lessens  the  immunity  and  increases 
the  susceptibility  to  infection.  The  period  of  incubation  is  so 
short  that  a  respiratory  disease  may  develop  before  the  body 
has  time  to  recover  its  strength.  This  fact  accounts  for  the  fre- 
quent de\-elopment  of  pneumonia  in  those  who  are  strong  and 
vigorous. 

The  evident  effects  of  cold,  fatigue,  and  dissipation  on  the 
feelings  and  actions  have  led  to  the  popular  belief  that  they  are 
the  essential  or  principal  factors  in  the  cause  of  colds  and  pneu- 
monia. They  are  only  passive  causes;  the  active  cause  is  always 
an  infection  with  the  specific  germs  of  the  disease. 

Duties  of  a  Health  Officer. — The  cause  of  an  acute  respira- 
tory disease  is  a  human  case  or  a  carrier;  and  the  measures  for 
its  control  are  similar  to  those  for  the  prevention  of  measles 
or  smallpox.  The  duties  of  a  health  officer  in  regard  to  acute 
respiratory  diseases  are: 

1.  The  discovery  of  cases. 

2.  The  isolation  of  affected  persons.  |^ 

3.  The  control  of  the  routes  of  infection.  » 


ACUTE   RESPIRATORY   DISEASES  247 

4.  Measures  for  increasing  immunity. 

5.  Educational  measures. 

Reporting  Cases. — Acute  respiratory  diseases  are  about  as 
contagious  as  measles,  and  a  health  officer  cannot  control  them 
unless  he  knows  where  cases  are.  The  reporting  of  all  cases  of 
pneumonia  and  influenza  by  physicians  is  necessary,  and  is  re- 
quired by  many  health  departments  and  boards  of  health. 

A  health  officer  may  have  to  search  for  cases,  especially  in  a 
school  or  an  institution.  Taking  the  temperatures  of  all  ex- 
posed persons  daily  may  be  necessary  in  order  to  detect  the  first 
signs  of  the  onset  of  the  disease. 

Isolation  of  known  cases  of  acute  respiratory  diseases  is  as 
necessary  as  isolation  for  diphtheria.  A  health  officer's  duty  is 
plain  in  fully  developed  pneumonia,  but  there  is  no  definite 
standard  by  which  he  can  judge  the  milder  cases.  A  number  of 
different  germs  may  cause  any  type  of  acute  respiratory  disease, 
and  it  is  not  always  possible  to  detect  the  specific  germ  in  a  given 
case.  It  is  the  duty  of  a  health  officer  to  inform  the  members 
of  an  affected  family  of  the  infectious  nature  of  the  sickness  and 
to  advise  them  in  the  methods  of  preventing  the  disease  from 
spreading. 

A  person  sick  with  an  acute  respiratory  disease  gives  off  \'iru- 
lent  disease  germs  in  the  sputum  and  other  discharges  from  the 
throat  and  nose.  The  measures  for  preventing  the  spread  of 
the  germs  are: 

1.  Collecting  and  destroying  the  sputum. 

2.  Cleanliness  of  the  patient,  the  sick  room,  and  everything 
in  the  room. 

3.  Precautions  by  the  attendants  to  avoid  taking  the  germs 
from  the  patient  by  droplet  infection,  and  soiled  hands.  Spe- 
cial precautions  are:  (a)  wearing  face  protectors  or  masks,  and 
(b)  washing  the  hands  immediately  after  handling  the  patient  or 
soiled  articles. 

4.  Disinfecting  the  dishes,  toilet  articles,  and  bed-clothing 
with  boiling  water. 

5.  Final  disinfection  of  the  room  and  its  contents  by  means 
of  cleanliness,  fresh  air,  and  sunshine.  The  germs  are  readily 
killed  by  the  ordinary  means  used  in  house  cleaning. 

The  length  of  time  for  continuing  the  isolation  of  a  case  can- 
not usually  be  determined  from  a  culture  from  the  nose  or  throat. 
A  practical  rule  is  to  continue  the  isolation  until  the  lungs,  nose, 
and  throat  are  in  a  normal  condition. 

It  is  a  necessary  rule  that  every  person  with  a  cold  or  cough 
shall  be  excluded  from  schools,  churches,  theaters,  and  other 
meeting  places.     An  acute  respiratory  disease  is  in  its  most 


248 


THE   HEALTH    OFFICER 


infective  stage  during  the  first  hours  of  its  onset.  There  is  no 
means  of  determining  whether  a  mild  fever  with  nose  or  throat 
signs  is  only  a  slight  cold,  or  is  the  beginning  of  a  deadly  pneu- 
monia. A  wise  rule  is  that  the  patient  shall  remain  in  isolation 
at  home  until  the  nature  of  the  sickness  can  be  determined. 

Control  of  the  Routes  of  Infection. — The  public  measures 
which  a  health  othccr  can  take  to  control  the  spread  of  acute 
respiratory  diseases  are: 

1.  The  adoption  and  enforcement  of  rules  and  regulations 
regarding  spitting. 

2.  Requiring  every  person  to  cover  the  nose  and  mouth  when 
coughing  or  sneezing.     The  departments  of  health  of  the  city 


Diagram  of  a  face  mask  made  from  a  paper  napkin. 


and  state  of  New  York  make  it  a  misdemeanor  for  any  one 
to  cough  or  sneeze  in  public  without  covering  the  nose  or 
mouth. 

3.  Closing  schools,  churches,  theaters,  and  other  meeting 
places.  This  is  a  measure  of  last  resort  to  be  used  when  there 
are  no  public  health  nurses  or  other  agencies  to  supervise  those 
who  attend  the  meeting  places. 

4.  Control  of  the  hours  of  opening  factories,  theaters,  and 
other  public  meeting  places  in  order  to  avoid  crowding  on  rail- 
roads and  street  cars. 

5.  Enforcing  cleanliness  of  streets,  railroad  stations,  cars, 
factories,  and  public  meeting  places. 

6.  Measures  to  prevent  the  spread  of  infection  in  crowded 
sleeping  quarters,  such  as  providing  at  least  3  feet  of  space  be- 


ACUTE   RESPIRATORY  DISEASES  249 

tween  beds;  placing  screens  or  hanging  sheets  between  the  beds; 
and  facing  the  heads  of  sleepers  in  opposite  directions  so  that  the 
head  of  one  person  is  opposite  the  feet  of  the  next. 

7.  Provision  for  treating  and  curing  persons  who  have  any 
of  the  diseases  or  a  chronic  cold. 

Face  Masks. — The  great  value  of  face  masks  is  to  prevent 
the  expulsion  of  infective  droplets  by  the  sick  or  carriers.  They 
prevent  the  entrance  of  moist  droplets,  but  they  are  of  little 
value  against  dust.  They  may  be  harmful  when  they  are  soiled 
and  contain  dried  sputum.  Two  layers  of  muslin  are  as  ef- 
ficient as  ten  of  coarse  gauze  in  preventing  the  expulsion  of 
droplets.  An  efficient  face  mask  that  is  recommended  by  the 
New  York  State  Department  of  Health  may  be  improvised  by 
folding  a  paper  napkin  according  to  the  diagram  on  page  248. 

Fold  A  upon  B,  and  C  upon  D.  Lay  a  tape  across  from  A  to 
C.  Fold  E  upon  F.  Tie  the  string  around  the  head  above  the 
ears. 

Increasing  Immunity. — Measures  to  increase  immunity  in- 
clude : 

1.  The  control  of  conditions  of  working,  feeding,  exercise, 
fatigue,  ventilation,  recreation,  and  exposure  to  excessive  damp- 
ness and  coldness. 

2.  The  control  of  other  diseases,  such  as  measles  and  whoop- 
ing-cough, which  often  lead  to  pneumonia. 

3.  The  use  of  vaccines. 

Extensive  experiments  have  been  made  to  determine  the 
value  of  vaccines  in  preventing  acute  respiratory  diseases. 
Streptococci  do  not  induce  immunity  to  pneumonia. 

Types  1,  2,  and  3  pneumococci  will  induce  a  high  degree  of 
immunity  to  those  types,  but  not  to  Type  4  or  to  other  organisms 
of  pneumonia. 

Influenza  bacilli  may  induce  an  immunity  to  the  strains 
that  were  used  in  making  the  vaccine. 

Education  of  the  Public. — The  preventive  measures  which 
can  be  carried  out  by  health  boards,  health  officers,  public  health 
nurses,  physicians,  and  other  persons  in  authority  are  only  about 
50  per  cent,  efficient  in  themselves  on  account  of  the  great 
number  of  mild  cases  or  carriers  which  do  not  come  to  the  atten- 
tion of  the  officials.  The  control  of  acute  respiratory  diseases  in 
a  community  requires  the  intelligent  co-operation  of  all  the  peo- 
ple. This  co-operation  will  not  be  secured  unless  the  people 
understand  the  elementary  principles  of  the  causes  of  the  dis- 
eases and  the  methods  of  their  spread.  The  ways  by  which  the 
diseases  are  spread  are  numerous,  and  a  lengthy  set  of  rules 
would  be  required  in  order  to  block  all  the  routes  of  infection. 


250  THE    HEALTH    OFFICER 

But.  fortunately,  the  foundation  principles  are  few  and  simple 
and  can  readily  be  grasped  by  an  ordinary  person. 

Intestinal  diseases  have  become  rare  because  the  people  are 
fairly  well  educated  regarding  the  dangers  from  the  excretions  of 
the  bowel,  and  bladder,  and  use  a  considerable  degree  of  care  in 
preventing  the  spread  of  the  excretions  from  one  person  to  an- 
other. But  the  people  are  not  yet  educated  regarding  the 
danger  from  spit  and  phlegm,  and  do  not  keep  in  mind  the 
methods  by  which  the  excretions  of  the  nose  and  throat  are 
spread.  Three  essential  things  which  every  person  should  know 
about  colds,  influenza,  pneumonia,  and  other  acute  infectious 
diseases  are: 

1.  They  are  caught  from  other  persons  who  have  the  disease. 

2.  They  are  spread  by  means  of  spit  and  phlegm. 

3.  The  essential  preventive  measures  are  included  in  the 
rules  of  good  manners  and  politeness. 

The  following  catechism^  may  be  used  in  teaching  the  people 
regarding  the  prevention  of  acute  respiratory  diseases: 
Q.  What  are  some  forms  of  colds? 
A.  1.  A  common  "cold  in  the  head." 

2.  Influenza  or  "grip." 

3.  Pneumonia. 

Q.  What  is  the  cause  of  a  cold? 

A.  Disease  germs  which  can  be  seen  and  measured.  There 
are  several  kinds  of  germs,  some  of  which  are  more  poisonous 
than  others;  but  the  most  poisonous  may  produce  only  a  mild 
cold  in  a  strong  person. 

Q.  Where  do  the  germs  grow? 

A.  In  the  noses  and  throats  of  persons. 

Q.  Who  are  likely  to  have  the  germs? 

A.  Four  classes  of  persons: 

1.  The  sick,  even  the  mildest  cases. 

2.  Those  about  to  be  sick. 

3.  Those  who  have  been  sick  and  have  recently  got  well. 

4.  Carriers,  or  those  in  whose  mouths  or  noses  the  germs 

grow  without  producing  sickness.  The  germs  in  car- 
riers do  not  grow  in  the  flesh,  but  on  the  surface  of 
the  lining  of  the  mouth  and  nose,  and  in  the  spit  and 
mucus. 

Q.  From  what  source  does  a  person  get  the  germs? 

A.  From  some  one  who  has  the  germs  in  the  nose  or  mouth. 

Q.  How  are  the  germs  given  off  from  the  body? 

A.  With  anything  that  comes  from  the  nose  or  mouth,  such 
as  saliva,  spit,  phlegm,  or  liquid  from  the  nose. 

^  Published  by  authority  of  the  Surgeon -General  of  the  Army. 


ACUTE   RESPIRATORY  DISEASES  251 

Q.  Where  are  living  disease  germs  likely  to  be  found  outside 
of  the  body? 

A.  On  anything  which  a  person  soils  with  saliva,  spit,  or 
phlegm.  For  example,  they  are  found  on  a  floor  on  which  a 
person  with  a  cold  has  spit,  and  on  a  towel  on  which  he  has 
wiped  his  face,  and  on  a  pillow  on  which  he  has  slept.  Any  dirt 
that  comes  from  a  person  with  a  cold  may  contain  the  disease  germs. 

Q.  What  are  the  principal  means  by  which  the  germs  are 
naturally  killed? 

A.  Sunhght,  drying,  and  cleanliness. 

Q.  How  long  will  the  germs  of  colds  live  outside  of  the  body? 

A.  Hours  and  days  in  places  which  are  dark,  damp,  and 
dirty;  only  an  hour  or  two  or  a  few  minutes  in  places  which  are 
sunny,  dry,  and  clean. 

Q.  When  will  the  germs  of  colds  be  found  on  floors,  bedding, 
dishes,  and  other  things? 

A.  When  these  things  are  dirty  and  damp.  The  germs  can- 
not live  on  things  which  are  clean  and  dry,  and  have  lain  in  the 
sunlight. 

Q.  Why  are  dishes  and  table  utensils  likely  to  spread  colds? 

A.  Because  they  are  soiled  with  saliva  and  spit  when  a  per- 
son eats  from  them.  If  they  are  washed  in  boiling  water  the 
germs  on  them  will  be  killed.  This  is  the  reason  for  boiling  the 
dishes  after  they  have  been  washed. 

Q.  When  will  the  air  contain  the  germs  of  colds? 

A.  1.  When  dust  floats  in  it. 

2.  When  an  affected  person  blows  germs  into  it.     The 
outdoor  air  is  nearly  always  free  from  disease  germs. 

Q.  What  kind  of  dust  contains  Kving  germs  of  colds? 

A.  That  rising  from  floors  and  things  which  are  soiled  with 
spit  and  phlegm.  The  living  germs  will  be  found  in  the  air  of 
rooms  in  which  persons  spit  on  the  floor. 

Q.  When  will  the  air  near  a  diseased  person  contain  disease 
germs? 

A.  When  he  blows  tiny  drops  of  spit  and  phlegm  into  the 
air.  He  will  blow  them  out  when  he  sneezes,  coughs,  laughs 
hard,  or  talks  loud. 

Q.  How  far  will  the  germs  float  in  the  air? 

A.  Only  2  or  3  feet,  for  the  drops  soon  fall  to  the  ground. 
You  are  safe  if  you  are  2  or  3  feet  from  a  diseased  person. 

Q.  What  are  the  most  common  means  of  spreading  disease 
germs? 

A.  1.  By  means  of  droplets  of  spit  and  phlegm. 

2.  By  means  of  soiled  toilet  articles. 

3.  By  means  of  soiled  hands. 


252  THE  HEALTH   OFFICER 

Q.  What  are  the  principal  means  of  keeping  disease  germs 
from  spreading? 

A.  1.  Quarantine  or  isolation. 

2.  Care  by  each  person  himself. 

3.  Cleanliness. 

Q.  Why  are  sick  persons  quarantined  or  isolated? 

A.  To  keep  them,  and  everything  that  they  have  used,  away 
from  other  persons. 

Q.  Why  may  the  quarantine  or  isolation  of  known  cases  fail 
to  stop  a  disease? 

A.  Because  a  physician  may  not  see  the  cases  until  a  few 
hours  after  the  disease  begins;  and  because  many  persons  do  not 
call  a  physician  when  they  are  only  slightly  sick. 

Q.  What  is  the  danger  from  those  who  have  only  slight  colds? 

A.  A  cold  may  be  caused  by  the  same  genns  that  will  pro- 
duce a  deadly  pneumonia  in  the  next  person. 

Q.  What  can  each  person  do  to  keep  from  catching  "cold? 

A.  1.  Keep  away  from  crowds. 

2.  Keep  your  face  2  or  3  feet    away  from  the  face  of 

another  person. 

3.  Cover   your   mouth    and   nose   when   you   cough   or 

sneeze. 

4.  Do  not  sneeze  or  cough  or  talk  loud  into  the  face  of 

another  person. 

5.  Use  clean  towels  and  other  toilet  articles.      Do  not 

use  any  which  have  been  used  by  another  person. 

Wear  a  nose   and  mouth  protector.     Many   other 

rules  could  be  made,  but  you  must  think  for  yourself 

and  use  common  sense.     The  rules  of  good  manners 

and    politeness    will    protect    you    from    colds    and 

influenza. 
Q.  What  parts  of  the  body  must  you  keep  clean  in  order  to 
keep  from  catching  cold? 

A.  The  hands,  the  mouth,  and  the  nose. 

Q.  Why  must  the  hands  be  washed? 

A.  1.  Disease  germs  may  stick  to  them  when  you  touch 

your  nose  or  mouth. 
2.  If  they  are  dirty,  you  may  carry  disease  germs  into 

your  mouth  when  you  eat.     Be  sure  to  wash  your 

hands  before  you  eat  or  handle  food. 
Q.  Why  is  cleanliness  of  the  mouth  and  nose  necessary? 
A.  1.  To  remove  the  germs  which  may  be  growing  there. 
2.  To  remove  disease  germs  before  they  have   time   to 

grow. 
Q.  How  can  you  cleanse  your  mouth? 


ACUTE   RESPIRATORY   DISEASES  253 

A.  Brush  the  teeth  morning  and  night.  Rub  the  tooth- 
brush over  the  top  of  the  tongue  and  the  roof  of  the  mouth. 
These  parts  become  as  dirty  as  the  teeth. 

Q.  How  can  you  cleanse  your  nose? 

A.  By  blowing  it.  Close  one  nostril  and  blow  through  the 
other.  Do  this  with  each  nostril.  Do  not  try  to  blow  both 
nostrils  at  the  same  time. 

Q.  What  is  the  cause  of  "mouth-breathing"? 

A.  The  nose  is  stopped  up. 

Q.  What  harm  comes  from  mouth-breathing? 

A.  One  harmful  result  is  that  disease  germs  may  be  held  in 
the  nose  and  cannot  be  blown  out.  If  you  cannot  blow  air 
through  a  nostril,  that  nostril  is  stopped  up  with  flesh  or  bone. 
Go  to  your  physician  and  let  him  treat  you  so  that  you  can 
breathe  through  your  nose. 


CIL-VPTER  XXIV 

INFECTIONS  OF  THE  DIGESTIVE  ORGANS 

Typhoid-colon  Group. — Acute  diarrheas  may  be  due  to  three 
causes:  1,  Irritating  substances,  such  as  green  fruit  or  spoiled 
food,  in  the  intestine;  2,  toxins  or  other  products  of  decompo- 
sition; and  3,  poisonous  bacteria  growing  in  the  intestine.  All 
three  causes  may  operate  together. 

The  intestine  is  a  natural  culture-tube  in  which  countless 
bacteria  grow.  The  majority  of  those  which  flourish  in  the 
intestine  form  a  closely  related  group,  consisting  of  the  colon, 
typhoid,  paratyphoid,  and  dysentery  bacilli,  of  which  there  are 
many  subspecies. 

The  colon  bacilli  naturally  inhabit  the  intestine  and  do  not 
usually  do  harm.  Some  of  the  colon  group  are  beneficial,  for 
they  produce  lactic  acid  and  have  a  marked  effect  in  restraining 
the  growth  of  the  organisms  of  disease  and  fennentation.  But 
sometimes  the  colon  bacilli  invade  the  tissues  and  produce  sick- 
ness. These  virulent  forms  of  the  colon  group  may  be  bacilli 
which  are  naturally  found  in  the  intestine,  and  which  are  able  to 
grow  on  account  of  a  loss  of  immunity  by  the  body,  or  they  may 
be  new  and  virulent  strains  introduced  from  outside  the  body. 
The  t}^hoid,  parat}phoid,  and  dysentery  members  of  the  group 
are  harmful  to  the  body,  although  certain  persons  may  have  an 
immunity  to  them  just  as  they  have  to  ordinary  colon  bacilli. 
The  typhoid  bacillus  is  the  best  known  and  most  common  of 
the  harmful  members  of  the  group. 

TYPHOID  BACILLI 

The  micro-organism  of  t>'phoid  fever  is  called  the  t\T3hoid 
bacillus.  It  has  numerous  flagellae,  and  is  in  constant  motion 
during  life.  The  characteristic  lesions  of  typhoid  fever  are 
swellings  and  ulcerations  of  the  l\Tnphoid  tissue  of  the  intestine. 
The  bacilli  are  plentiful  in  the  blood  during  the  first  week  of 
the  disease,  and  through  it  they  reach  every  part  of  the  body. 
They  have  been  found  growing  in  lesions  in  the  lungs,  central 
nervous  system,  bones,  liver,  spleen,  and  other  parts  of  the  body. 
They  are  constantly  found  in  the  contents  of  the  intestine,  and 
in  about  half  of  the  cases  in  the  urine  also.  The  fever  and 
prostration  of  the  disease  are  due  partly  to  poisons  developed  by 

254 


INFECTIONS    OF   THE   DIGESTIVE    ORGANS 


255 


the  germs  in  the  blood  and  tissues,  partly  to  poisons  absorbed 
from  the  intestines,  and  partly  to  streptococci,  colon  bacilli, 
and  other  bacteria  which  may  grow  with  the  specific  typhoid 
bacilli  of  the  disease. 

Typhoid  bacilli  may  be  found  in  anything  that  is  soiled  or 
contaminated  with  the  discharges  of  a  typhoid  patient.  They 
may  remain  alive  in  sewage,  water,  milk  and  other  foods,  and 
on  the  hands  of  nurses  who  care  for  the  patients.  A  person 
catches  typhoid  fever  by  swallowing  something  which  has  been 


Fig.  14. — Method  of  transmission  of  typhoid  fever. 


contaminated  with  the  excretions  of  those  afflicted  with  the 
disease  or  who  are  carriers  of  the  germs. 

Susceptibility. — The  susceptibihty  of  persons  to  tj-phoid 
infection  varies  greatly.  Gastric  juice  of  good  quality  has 
great  power  to  digest  the  bacilh  which  are  swallowed,  and  a 
healthy  epithelial  lining  of  the  intestine  has  a  considerable 
resistance  against  them,  but  if  a  person  has  a  gastric  indiges- 
tion or  an  intestinal  disturbance,  the  typhoid  bacilh  may  gain 
lodgment  in  the  intestine  and  may  produce  the  disease.      A 


256  THE   HEALTH    OFFICER 

water-borne  outbreak  of  typhoid  is  often  preceded  by  the  de- 
velopment of  many  cases  of  simple  diarrhea.  These  cases  may 
come  from  two  causes.  When  typhoid  bacilli  enter  the  water, 
the  bacteria  of  diarrhea  and  other  common  intestinal  disturb- 
ances enter  it  also,  and  the  two  sources  of  infection  may  exist 
together.  Also  many  dead  bacilli  and  products  of  their  action 
may  enter  the  body  and  produce  a  simple  poisoning  or  toxemia. 
Both  of  these  conditions  produce  a  susceptibiUty  to  typhoid 
bacilH,  and  may  be  secondary  factors  in  producing  typhoid. 

Recognition  of  Typhoid  Fever. — Typhoid  fever  produces  a 
fever  whose  onset  is  slow  and  insidious.  There  are  usually 
vague  and  indetinite  pains  in  the  abdomen,  and  a  disturbance  of 
the  intestine.  A  slow,  persistent  course  of  these  three  symptoms 
is  suggestive  of  typhoid  fever.  The  disease  in  a  mild  form,  or 
walking  tNphoid,  is  often  unrecognized  for  days  and  weeks,  for 
the  signs  are  those  of  an  ordinary  intestinal  disturbance.  If  the 
sjTnptoms  persist  for  a  few  days,  even  in  a  mild  form,  without 
positive  signs  of  some  other  disease  to  account  for  them,  it  is 
the  duty  of  the  physician  or  health  officer  to  take  the  neces- 
sary steps  to  make  a  positive  diagnosis,  and  to  begin  the  pro- 
tective and  preventive  measures  against  the  spread  of  the  dis- 
ease. Three  positive  diagnostic  signs  are  the  presence  of  the 
bacilh  in  the  blood,  the  agglutination  of  a  pure  culture  of  typhoid 
germs  by  the  blood-serum  of  the  suspected  person,  and  the 
presence  of  typhoid  bacilli  in  the  intestinal  excretions. 

Blood-culture. — A  culture  made  from  the  blood  will  usually 
reveal  the  bacilli  during  the  first  week  of  the  disease.  The 
bacilh  may  disappear  during  the  second  week.  The  culture  is 
made  by  obtaining  a  fresh  supply  of  the  proper  culture-medium 
from  a  laboratory  and  inoculating  it  with  blood  drawn  from  a 
vein  with  a  sterile  syringe.  If  the  culture-medium  is  not  at  hand, 
the  blood  may  be  inoculated  into  about  ten  times  its  bulk  of 
sterilized  distilled  water  and  taken  to  the  laboratory  as  quickly 
as  possible.  The  bacilli  which  develop  may  be  recognized  by 
means  of  agglutination  tests  made  with  a  serum  containing 
typhoid  antibodies. 

The  Widal  reaction,  or  the  test  for  agglutinating  antibodies 
in  the  blood-serum  of  suspected  cases,  is  a  simple  and  reliable 
laboratory  test  for  typhoid  fever.  The  method  of  performing  it 
is  described  on  page  147.  A  positive  reaction  appearing  promptly 
in  a  serum  dilution  of  1  :  40  indicates  typhoid  fever.  The  anti- 
bodies usually  begin  to  appear  in  the  blood  during  the  second 
week  of  the  sickness,  but  they  may  be  delayed  until  the  third 
or  fourth  week,  and  in  rare  cases  they  may  not  be  present  at  all. 
They  usually  persist  for  years  after  recovery  from  typhoid,  and 


INFECTIONS    OF   THE   DIGESTIVE    ORGANS  257 

are  present  after  vaccination  with  typhoid  bacilli.  They  are 
usually  present  in  the  blood  of  carriers  of  typhoid  bacilli. 

A  Widal  reaction  will  be  given  by  those  who  have  been  vac- 
cinated with  typhoid  bacilli.  Always  inquire  whether  or  not  the 
person  from  whom  a  specimen  is  taken  has  received  typhoid  vaccine. 

The  agglutination  test  may  be  made  with  fresh  blood-serum, 
or  with  serum  from  a  blister,  or  with  dried  blood.  It  is  the  duty 
of  every  health  officer  to  know  how  to  take  samples  of  blood  for 
a  Widal  test.  The  method  of  taking  a  sample  of  dried  blood  is 
as  follows: 

1.  Use  alcohol  and  sterilize  (a)  the  back  of  the  finger  just 
behind  the  nail;  (b)  a  needle  (Hagedorn);  (c)  a  microscope  slide. 

2.  Prick  the  sterilized  flesh  with  a  quick  stab  of  the  needle 
and  press  out  a  drop  of  blood. 

3.  Apply  the  slide  to  the  blood,  making  two  or  three  spots. 

4.  Allow  the  specimen  to  dry,  wrap  it  in  a  clean  paper,  and 
send  it  to  a  laboratory  for  examination. 

Typhoid  Carriers. — The  bacilli  which  cause  typhoid  fever 
grow  in  the  blood  during  the  incubation  period  and  early  stage 
of  the  sickness,  and  may  not  be  found  in  the  intestinal  excretions 
until  the  second  week  of  the  disease  or  later.  Great  numbers 
may  usually  be  found  in  the  excretions  after  the  first  week.  They 
usually  diminish  in  number  during  the  stage  of  convalescence, 
and  are  entirely  gone  by  the  time  the  patient  has  recovered ;  but 
they  persist  in  about  1  per  cent,  of  cases.  They  may  continue 
to  grow  in  the  gall-bladder  and  bile-ducts  and  in  other  parts  of 
the  intestine.  A  person  in  whom  they  persist  is  called  a  typhoid 
carrier,  and  is  a  source  of  danger  to  other  persons.  The  most 
practical  means  of  detecting  a  typhoid  carrier  is  by  finding  the 
typhoid  bacilli  in  the  intestinal  excretions.  Typhoid  bacilli  are 
also  sometimes  found  in  the  urine  of  carriers. 

Examination  of  Intestinal  Excretions. — The  typhoid  bacilli 
in  intestinal  excretions  are  always  mixed  with  colon  bacilli  and 
other  bacteria.  The  detection  of  typhoid  bacilli  depends  on 
their  enrichment  by  their  growth  on  a  medium  unfavorable  to 
the  associated  organisms  (page  136).     The  method  is  as  follows: 

1.  Prepare  a  lactose-agar  medium  to  which  a  minute  quantity 
of  the  dye,  brilliant  green,  is  added,  and  pour  it  into  Petri  dishes. 

2.  Rub  a  small  quantity  of  intestinal  excretions  with  about 
fifteen  times  its  volume  of  water  and  let  it  stand  for  half  an  hour. 

3.  Take  a  loopful  of  the  surface  layer  of  the  liquid  and  streak 
it  over  the  surface  of  the  medium  and  incubate  it  for  about 
twelve  hours. 

4.  Choose  a  typical  colony  and  test  its  agglutination  with 
typhoid  serum. 

17 


258  THE  HEALTH   OFFICER 

While  typhoid  bacilli  may  exist  for  days  in  infected  water 
and  food,  their  cultivation  is  difficult  and  uncertain  a  few  hours 
after  the  intestinal  discharges  have  left  the  body,  for  colon  bacilli 
and  other  intestinal  organisms  tend  to  multiply  and  overgrow 
them.  It  is  necessary  that  the  fresh  excretions  be  used  for  a 
test.  A  health  officer  may  take  a  specimen  from  the  fresh  ex- 
cretions with  a  sterile  swab  of  cotton,  enclose  it  in  a  sterile  test- 
tube,  and  send  it  to  a  laboratory  as  quickly  as  possible.  The 
New  York  State  Department  of  Health  supplies  health  officers 
with  mailing  outfits  for  taking  samples  for  typhoid  culture 
tests. 

Typhoid  Vaccination. — When  a  vaccine  of  killed  typhoid 
bacilli  is  injected  into  the  body,  it  produces  antibodies  which 
consist  of  agglutinins  and  also  of  substances  which  protect  the 
body  against  living  typhoid  bacilli.  The  protection  afforded  by 
the  vaccination  has  been  tested  on  a  large  scale  in  the  American 
Army,  and  its  effectiveness  proved.  It  is  not  an  absolute  pro- 
tection, but  it  will  protect  against  an  amount  of  infection  which 
a  person  is  likely  to  take  into  the  body.  The  protection  lasts  for 
at  least  two  or  three  years. 

Vaccination  done  after  a  person  has  been  infected  with 
typhoid  bacilli  hastens  the  onset  of  the  sickness  and  the  develop- 
ment of  the  disease,  but  it  shortens  the  course  of  the  fever.  It 
is  of  httle  or  no  value  in  the  treatment  of  the  fever. 

T}-phoid  vaccine  is  given  subcutaneously  into  the  arm  over 
the  insertion  of  the  deltoid  muscle.  Three  doses  are  given  a 
week  apart,  the  first  of  500,000,000,  the  second  and  third  of 
1,000,000,000  bacteria.  A  single  dose  confers  very  httle  immu- 
nity, and  many  of  the  cases  of  typhoid  after  vaccination  have  fol- 
lowed insufficient  amounts.  The  injections  produce  a  soreness 
at  the  site  of  injection,  and  a  slight  fever  and  feeling  of  sickness. 
The  Department  of  Health  of  New  York  State  supphes  health 
officers  with  the  material  for  t>^hoid  vaccinations. 

A  practical  and  efficient  form  of  material  for  antityphoid 
inoculation  is  that  known  as  lipo  vaccine,  in  which  the  bacteria 
are  suspended  in  oil  instead  of  water.  The  three  doses  may  be 
given  at  once,  for  the  oil  retards  their  absorption. 

Disinfection  of  Excretions. — The  routes  by  which  typhoid 
bacilli  usually  leave  the  body  are  the  intestine  and  bladder,  and 
millions  of  the  bacteria  are  found  in  the  excretions  of  these  two 
organs  in  typhoid  cases  and  carriers.  The  disinfection  of  these 
two  excretions  is  one  of  the  great  problems  in  sanitation.  One 
method  of  disinfection  is  by  means  of  heat.  Various  devices 
have  been  invented  for  boiling  the  excretions  without  producing 
odors.     They  are  successful  in  camps  and  hospitals  where  ex- 


INFECTIONS    OF   THE   DIGESTIVE   ORGANS  259 

perts  are  in  attendance,  but  they  arc  impractical  for  an  ordinary 
health  ofificer. 

Chemicals  are  frequently  used  for  disinfecting  typhoid  ex- 
cretions. Unslaked  lime  is  often  used,  but  its  action  depends 
upon  the  heat  that  is  generated  by  the  slaking  and  not  upon 
any  special  disinfecting  quality  of  the  lime  itself.  Two  dif- 
ficulties with  disinfectants  are  the  penetration  of  masses  which 
are  jelly-like  or  solid,  and  the  length  of  time  required  for  the 
destruction  of  the  bacilli.  They  are  about  80  per  cent,  eflficient, 
and  a  health  officer  cannot  rely  on  them  alone.  The  method  of 
disinfection  recommended  by  the  New  York  State  Department 
of  Health  is  as  follows : 

Prepare  a  solution  of  chlorid  of  lime  by  adding  ^  pound  to 
1  gallon  of  water.  Pour  about  a  pint  of  the  solution  into  the 
vessel  in  which  the  excretions  are  to  be  received.  Pour  over  them 
an  amount  of  the  solution  equal  to  twice  the  volume  of  the  excre- 
tions. Stir  the  contents  of  the  vessel  and  allow  them  to  stand  for 
an  hour  before  emptying  them. 

The  final  disposal  of  excretions  is  of  the  utmost  importance 
even  when  disinfectants  are  used.  If  the  plumbing  of  a  house  is 
connected  with  a  public  sewer,  the  discharges  may  be  emptied 
into  it,  for  the  final  destruction  of  typhoid  bacilH  is  supposed  to 
be  done  at  the  disposal  plant.  If  the  house  plumbing  is  connected 
with  a  private  cesspool  which  is  in  good  order,  the  excretions  may 
be  emptied  into  the  toilet  receptacle.  The  excretions  may  be 
safely  emptied  into  an  outdoor  toilet  only  when  its  receptacle  is 
water-tight  and  fly-proof.  The  most  practical  method  of  their 
disposal  in  the  country  is  by  burial  in  the  soil.  Provide  a  deep 
hole  at  least  2  feet  square,  and  cover  each  collection  of  excre- 
tions at  once  with  at  least  6  inches  of  soil.  Use  the  hole  until 
it  is  half  filled,  and  then  dig  another  one.  If  the  ground  is 
frozen,  the  health  officer  must  devise  some  method  of  prevent- 
ing the  excretions  from  being  washed  away  during  the  spring 
thaws. 

Management  of  a  Case. — When  a  case  of  typhoid  fever  de- 
velops, the  first  duty  of  the  health  ofificer  is  to  shut  off  all  the 
avenues  by  which  the  disease  spreads.  The  infective  material 
is  not  air-borne,  nor  spread  by  droplets  of  saliva  or  nasal  mucus, 
nor  by  ordinary  dust  from  dried  material.  A  strict  isolation  or 
quarantine  is  therefore  unnecessary.  Since  the  typhoid  bacilli 
are  contained  in  the  excretions  of  the  intestine  and  bladder,  the 
precautions  are  directed  against  the  routes  by  which  excretions 
may  be  carried  from  the  patient  to  other  persons  even  in  minute 
amounts.  The  protective  measures  which  a  health  ofi&cer  must 
take  are  as  follows : 


260  THE   HEALTH   OFFICER 

1 .  Exclude  all  persons,  except  the  necessan^  attendants,  from 
close  contact  with  the  patient.  A  near  friend  or  rclati\'e  who 
calls  may  sit  beside  the  patient  if  the  bed  is  covered  with  a  clean 
sheet  and  the  visitor  does  not  touch  the  patient. 

2.  Secure  an  intelligent  and  capable  nurse  who  will  observe 
the  necessary  precautions.  There  is  great  danger  of  spreading 
infection  if  a  mother  cares  for  a  case  and  at  the  same  time  does 
the  cooking  and  household  work  for  her  family.  It  will  pay  a 
communit}-  to  hire  a  competent  nurse  at  public  expense  if  the 
family  cannot  afTord  to  employ  one. 

3.  Provide  a  disinfecting  solution,  at  public  expense  if 
necessary,  and  give  instructions  to  the  nurse  and  other  attend- 
ants that  they  shall  keep  a  bowl  of  it  ready  at  all  times,  and 
shall  wash  their  hands  immediately  after  doing  anything  to  the 
patient  or  handling  the  bed,  or  soiled  clothes,  or  excretions. 
Warn  the  attendants  against  putting  their  soiled  hands  to  their 
mouths. 

4.  Exclude  flies  from  the  room  and  from  contact  with  the 
excretions  or  soiled  clothes  and  dishes  of  the  patient. 

5.  Pay  special  attention  to  the  disinfection  and  disposal  of 
excretions,  and  to  the  cleansing  of  the  vessels  in  which  they  are 
handled.  A  health  olhcer  must  make  a  personal  inspection  of 
the  place  in  which  the  excretions  are  finally  emptied,  and  give 
detailed  orders  for  their  disposal. 

6.  Boil  all  used  dishes  before  they  are  washed.  Provide  a 
wash-boiler  for  receiving  soiled  clothes,  towels,  and  other  ar- 
ticles that  are  used  by  the  patient,  and  boil  them  before  they 
are  laundered.  If  they  are  kept  protected,  and  are  boiled,  there 
will  be  no  need  for  soaking  them  in  a  disinfecting  solution. 

7.  Inquire  into  the  occupations  in  which  the  well  members 
of  the  family  are  engaged,  and  exclude  them  from  handling  food 
so  long  as  they  live  at  home  or  come  in  contact  with  the  patient. 
A  milkman  must  leave  the  house,  and  keep  all  the  dairy  utensils 
away  from  it.  The  New  York  Sanitary  Code,  Chapter  2, 
Regulations  37-39,  has  detailed  directions  regarding  handling 
foods  by  persons  who  may  come  in  contact  with  cases  of  typhoid 
and  other  communicable  diseases. 

Epidemiology. — A  health  ofhcer  has  not  completed  his  duty 
when  he  has  instituted  the  measures  for  the  control  of  a  case  of 
typhoid  fever.  The  case  originated  from  another,  and  it  is  the 
duty  of  the  health  officer  to  find  the  original  one  and  to  break 
up  the  route  over  which  the  bacilli  traveled  to  reach  the  patient. 
If  he  can  find  either  the  original  case  or  the  route  of  transmission 
of  the  disease,  he  will  usually  be  about  90  per  cent,  successful 
in  controling  the  spread  of  the  disease.     If  he  can  find  both  the 


INFECTIONS   OF  THE   DIGESTIVE   ORGANS  261 

original  case  and  the  route  of  its  transmission,  he  can  score 
100  per  cent,  of  success.  He  will  conduct  the  investigation  along 
the  lines  indicated  on  page  179. 

When  a  health  officer  starts  to  investigate  an  outbreak  of 
typhoid  fever,  the  first  thing  for  him  to  do  is  to  obtain  a  history 
of  each  case  with  special  reference  to  the  dates  of  onset  of  the 
sickness,  and  to  what  each  patient  was  doing  during  the  time 
when  he  became  infected.  The  date  of  onset  is  usually  given 
as  that  on  which  the  patient  took  to  bed,  but  there  have  usually 
been  indefinite  pains  and  other  signs  of  sickness  which  the 
patient  or  members  of  the  family  can  recall.  The  date  of  onset 
of  the  sickness  may  usually  be  considered  to  be  the  date  on  which 
the  first  definite  signs  were  noticed.  The  date  on  which  infec- 
tion occurred  is  the  important  date  which  a  health  officer  seeks. 
It  will  usually  be  a  week  or  ten  days  previous  to  the  date  of  on- 
set, but  it  may  be  only  four  or  five  days,  or  as  much  as  three 
weeks. 

The  health  officer  will  make  diligent  inquiry  concerning  the 
actions  of  the  patient  about  the  time  when  infection  could  have 
occurred.  He  will  have  in  mind  the  four  great  public  routes — 
water,  milk,  food,  and  flies — over  which  the  infectious  material 
may  have  been  carried  to  the  patient  from  a  distant,  unknown 
case,  and  also  the  private  route  of  direct  contact  with  a  nearby 
known  case.  The  investigation  in  a  typhoid  fever  epidemic  will 
be  more  complicated  than  that  in  any  other  disease,  for  the  pos- 
sible sources  of  infection  are  many.  The  patients  themselves 
are  often  unable  to  recall  clearly  where  they  have  been,  what  they 
have  eaten,  and  whom  they  have  met. 

If  there  are  a  number  of  cases,  an  analysis  of  the  data  will 
reveal  the  elements  which  are  common  to  many  or  all  of  the 
cases.  Dates  of  onset  near  together  would  indicate  a  common 
source  of  infection,  such  as  a  banquet,  picnic,  excursion,  or  a  flood- 
ing of  the  public  water-works.  An  interval  of  a  week  or  so 
between  two  series  of  cases  would  point  to  a  spread  of  infection 
from  the  original  cases  to  secondary  ones. 

Water  as  a  source  of  infection  would  be  indicated  by  a  dis- 
tribution of  the  cases  over  the  whole  area  supplied  by  the  water, 
and  would  be  confirmed  or  disproved  by  an  analysis  of  the  water 
and  an  inspection  of  the  water-shed. 

Infection  through  milk  would  be  indicated  by  the  distribu- 
tion of  the  cases  along  a  particular  milk  route,  and  a  health 
officer  would  follow  up  the  clue  by  an  investigation  of  the  work- 
men in  the  dairies  and  on  the  farms  from  which  the  milk  is 
obtained. 

The  transmission  of  typhoid  by  food  would  be  indicated  by 


262  THE   HEALTH    OFFICER 

a  common  source  of  food,  such  as  a  banquet  or  a  particular 
restaurant.  The  source  of  the  bacilli  will  usually  be  found  to  be 
a  carrier  who  has  recently  started  work.  The  possibility  of 
infected  oysters  must  also  be  remembered. 

Another  source  of  food  infection  is  green  foods  which  are 
eaten  raw,  such  as  celery  and  lettuce.  The  infection  may  come 
from  sewage  or  house  slops  used  in  watering  the  garden,  or 
from  an  infected  brook  or  drain  in  which  the  vegetables  were 
washed.  These  sources  are  improbable,  and  yet  the  disease 
now  spreads  principally  by  unusual  and  unsuspected  routes,  for 
the  usual  routes  are  watched  and  guarded. 

The  occurrence  of  cases  in  summer  and  early  fall  among 
those  who  Hve  amid  unsanitary  surroundings  would  point  to 
flies  as  the  source  of  infection.  Confirmatory  evidence  would 
be  the  presence  of  flies  and  of  open  privies,  and  further  e\'idence 
would  be  the  occurrence  of  cases  of  persistent  intestinal  disorders 
in  the  neighborhood. 

The  detection  of  the  great  routes  of  transmission  of  typhoid 
fever,  and  the  discovery  of  cases  who  are  sick  in  bed,  are  compara- 
tively easy,  but  it  takes  persistent  efTort  to  discover  carriers. 
A  carrier  may  have  had  only  a  mild  sickness  many  years  pre- 
viously, and  may  be  inclined  to  conceal  the  fact,  or  may  have 
forgotten  it.  A  t}'phoid  carrier  may  be  recognized  by  the  Widal 
test  and  by  an  examination  of  the  intestinal  discharges.  Nearly 
all  carriers  gi\e  a  positive  Widal  reaction,  for  they  are  immune  to 
typhoid  bacilli. 

If  a  health  officer  suspects  a  person  to  be  a  t>TDhoid  carrier, 
his  first  procedure  will  be  to  take  a  sample  of  blood.  If  the 
Widal  test  is  positive,  his  next  step  will  be  to  take  a  specimen 
of  the  intestinal  discharges.  He  has  no  direct  power  to  compel 
a  healthy  person  to  provide  a  specimen  for  examination,  but  he 
can  use  indirect  means  to  secure  it.  Most  persons  will  yield 
to  explanation  and  persuasion,  or  their  employers  will  compel 
them  to  yield.  Making  routine  examinations  of  the  blood  and 
of  the  discharges  of  suspected  persons  has  enabled  the  New  York 
State  Department  of  Health  to  do  brilliant  work  in  discovering 
carriers  who  have  been  the  innocent  causes  of  the  continual 
existence  of  t^-phoid  fever  in  their  neighborhoods  for  years. 

When  a  health  offtcer  has  discovered  a  t}'phoid  carrier,  the 
great  problem  is  what  to  do  with  the  person.  The  measures 
which  the  health  officer  may  take  are: 

1.  Exclude  the  carrier  from  occupations  in  which  food  is 
handled. 

2.  Teach  the  carrier  personal  cleanliness  and  the  proper  dis- 
posal of  his  excretions. 


INFECTIONS    OF   THE   DIGESTIVE    ORGANS  263 

3.  Advise  the  carrier  to  undergo  an  operation  for  the  re- 
moval of  the  gall-bladder.  This  operation  is  effective  in  about 
half  of  the  cases. 

4.  Advise  the  carrier  to  take  the  typhoid  vaccination  repeat- 
edly with  the  object  of  inducing  a  higher  degree  of  immunity 
which  will  overcoriie  the  germs. 

PARATYPHOID   FEVER 

Bacteriologic  studies  have  shown  that  there  are  bacilli  which 
closely  resemble  those  of  typhoid  fever,  and  which  produce  a 
disease  which  can  scarcely  be  distinguished  from  typhoid,  but 
which  differ  from  typhoid  bacilli  almost  as  much  as  from  colon 
bacilli.  These  baciUi  are  called  paratyphoid  bacilli.  Their 
distinct  identity  is  shown  by  their  pecuHar  growths  on  culture- 
media,  their  failure  to  agglutinate  with  higher  dilutions  of 
typhoid  serum,  and  the  failure  of  typhoid  vaccination  to  protect 
against  infection  with  them. 

Paratyphoid  fever  occurs  either  in  isolated  cases  or  in  epi- 
demics. It  is  spread  in  the  same  manner  as  typhoid,  and  the 
same  procedures  are  used  for  its  detection  and  prevention.  There 
may  be  healthy  carriers  of  paratyphoid  bacilli,  and  a  vaccine  of 
the  killed  bacilli  is  efficient  as  a  preventive  against  the  disease. 
A  health  officer  must  always  have  the  disease  in  mind  in  making 
a  diagnosis  of  a  case  that  is  suspected  to  be  typhoid,  and  in 
doubtful  cases  it  is  his  duty  to  request  that  an  agglutination 
test  be  made  with  paratyphoid  serum  as  well  as  with  that  of 
typhoid. 

Paratyphoid  bacilli  are  themselves  divided  into  two  groups, 
A  and  B ,  which  may  be  detected  by  their  cultural  and  agglutina- 
tion characteristics.  Paratyphoid  bacilli  A  usually  produce  a 
severe  form  of  disease  whose  symptoms  and  course  resembles 
those  of  a  well-marked  case  of  typhoid  fever.  Paratyphoid 
bacilli  B  usually  produces  a  mild  type  of  sickness  which  re- 
sembles an  acute  gastro-intestinal  disturbance,  and  which  lasts 
only  a  few  days.  The  duties  of  a  health  officer  in  paratyphoid 
fever  are  the  same  as  those  in  typhoid.  Inoculations  of  killed 
bacilli  are  effective  in  producing  immunity.  The  triple  vaccine 
used  in  the  American  Army  consists  of  typhoid  bacilli,  para- 
typhoid A,  and  paratyphoid  B. 

Paratyphoid  Bacilli  and  Food  Poisoning.— Some  bacilli  of 
the  paratyphoid  group  may  grow  in  cattle  and  produce  a  sep- 
ticemia. The  bacilli  will  grow  readily  in  the  meat  of  diseased 
cattle.  They  may  be  transferred  from  one  piece  of  meat  to 
another  by  contact.  The  bacilli  produce  toxins  which  are  not 
destroyed  by  the  heat  of  ordinary  cooking.     When  a  person 


264  THE  HEALTH   OFFICER 

eats  meat  that  is  infected  with  paratyphoid  bacilli,  the  effects 
will  depend  largely  on  whether  the  bacilli  arc  alive  or  dead.  If 
thev  are  alive,  they  may  produce  a  paratyphoid  fever.  If  the 
bacilli  are  killed  by  cooking,  their  toxins  may  remain  active  and 
produce  an  acute  gastro-intestinal  disturbance  which  usually 
comes  on  within  from  half  an  hour  to  twelve  hours,  depending 
on  the  rapidity  of  absorption  of  the  poisons. 

Most  cases  of  so-called  ptomain  poisoning  are  caused  by 
infection  with  paratyphoid  bacilli.  When  a  health  ofhcer  hears 
of  a  number  of  cases  of  food  poisoning,  the  proper  course  for  him 
to  take  is: 

1.  Secure  some  of  the  food  and  send  it  to  a  laboratory  as 
soon  as  possible  for  examination. 

2.  Secure  samples  of  the  intestinal  excretions  of  the  patients 
and  send  them  to  the  laboratory  to  be  examined  for  paratyphoid 
bacilli  and  other  organisms. 

3.  Take  precautions  against  the  spread  of  the  disease  until  a 
positive  diagnosis  is  made. 

4.  After  a  week  or  two  secure  a  sample  of  blood  of  the  pa- 
tients for  agglutination  tests. 

BACILLARY  DYSENTERY 

Dysentery  is  a  name  applied  to  any  disease  in  which  the 
mucous  membrane  of  the  large  intestine  is  inflamed  or  gan- 
grenous. It  may  be  recognized  by  a  diarrhea  with  frequent 
discharges  of  mucus  and  blood.  An  acute  form  which  sometimes 
occurs  in  epidemics  is  caused  by  a  specific  bacterium,  the  dysen- 
tery bacillus,  which  belongs  to  the  typhoid-colon  group.  It 
resembles  the  typhoid  bacillus  in  its  manner  of  growth  and 
production  of  agglutinins.  It  is  found  in  the  intestinal  excre- 
tions, and  may  be  recognized  by  the  same  methods  of  culture 
and  agglutination  by  which  the  typhoid  bacillus  is  isolated  and 
identified.  A  diagnosis  is  made  by  agglutination  tests  and  by  a 
bacteriologic  exarnination  of  the  intestinal  excretions.  There 
may  be  mild,  unrecognized  cases  of  the  disease  and  healthy  car- 
riers of  the  bacilli.  A  curative  serum  may  be  made  for  some 
forms  of  the  disease.  Dysentery  spreads  in  the  same  manner, 
and  may  be  controlled  by  the  same  methods  as  typhoid  fever. 
A  health  ofhcer  will  investigate  an  epidemic  in  the  same  manner 
that  he  would  a  typhoid  outbreak,  and  will  follow  the  same  meth- 
ods of  control. 

There  are  several  varieties  of  the  dysentery  bacillus  just  as 
there  are  of  the  paratyphoid  bacillus.  They  may  be  recognized 
by  cultural  and  agglutination  tests.  Two  types  which  are  well 
known  are  those  of  Shiga  and  of  Flexner.     An  extensive  epi- 


INFECTIONS    OF   THE   DIGESTIVE    ORGANS  265 

demic  of  the  disease  that  occurred  in  New  York  State  in  1916 
was  caused  by  the  Flexner  type  of  bacillus,  and  was  started  by 
mild  cases  and  carriers.  A  curative  serum  was  used  with 
prompt  success  in  treating  the  cases. 

It  is  probable  that  unrecognized  cases  of  bacillary  dysentery 
occur  every  year.  A  health  officer  must  keep  the  disease  in 
mind  and  ask  for  the  assistance  of  the  State  Department  of  Health 
when  he  suspects  its  presence. 

A  vaccine  composed  of  killed  dysentery  bacilli  produces 
immunity  to  the  disease.  A  curative  serum  of  great  value  is 
also  produced,  and  is  potent  against  the  type  of  bacilli  that  was 
used  in  producing  the  serum,  and  less  potent  against  other  types. 
Uniformly  satisfactory  results  are  attained  only  when  the  serum 
suitable  to  the  type  of  dysentery  is  used,  as  in  pneumonia. 

Amebic  Dysentery. — A  form  of  dysentery  that  occurs  in  the 
tropics  is  caused  by  an  ameba.  It  has  no  relation  to  the  epi- 
demic form  that  occurs  in  temperate  regions. 

Common  Forms  of  Dysentery. — The  mild  forms  of  dysentery, 
called  summer  complaints,  are  caused  by  bacilli  belonging  to 
the  typhoid-colon  group,  and  are  analogous  to  the  colds  which 
affect  the  respiratory  organs.  They  are  infectious  and  every 
case  probably  develops  after  swallowing  the  bacilli  from  a 
previous  case.  It  is  probable  that  a  great  diminution  in  the 
number  of  babies  who  suffer  with  the  disease  would  follow  an 
isolation  of  every  baby  that  has  the  disease,  its  protection  from 
flies,  the  disinfection  of  its  excretions,  and  the  cleansing  and 
disinfection  of  its  body  after  every  bowel  movement.  The 
pubhc  needs  education  regarding  the  infectiousness  of  ordinary 
forms  of  diarrhea  and  dysentery  just  as  it  does  regarding  the 
infectiousness  of  a  common  cold. 

CHOLERA 

Cholera  Vibrio. — Cholera  is  caused  by  a  curved  bacterium 
called  the  cholera  vibrio  or  spirillum.  It  has  no  relation  to  the 
typhoid-colon  group  of  bacilli.  It  may  be  recognized  by  its 
curved  form  and  rapid  motion.  It  grows  in  the  lining  of  the 
intestine,  and  destroys  the  epithelium  of  the  mucous  membrane. 
The  severe  symptoms  are  caused  by  an  absorption  of  the  poisons 
through  the  raw  surface.  The  signs  of  the  disease  are  those  of 
a  severe  diarrhea  with  great  weakness.  The  bacteria  are  given 
off  with  the  intestinal  discharges,  and  their  entrance  into  an- 
other person  is  by  way  of  the  mouth.  The  routes  by  which  they 
are  spread  are  infected  water  and  food,  and  by  contact.  There 
are  healthy  carriers,  but  they  may  suddenly  develop  the  disease 
when  they  overeat  or  otherwise  abuse  their  stomachs.    Those 


266  THE    HEALTH    OFFICER 

who  recover  from  the  disease  niay  remain  carriers  for  a  month 
or  two,  but  there  are  no  chronic  carriers  as  in  tj^^hoid  fever. 

Cholera  was  formerly  a  common  disease  in  Europe  and 
America,  but  sanitation  and  the  protection  of  water-supplies 
have  made  it  a  rare  disease  in  most  civilized  lands.  But  cases 
often  reach  New  York  City,  and  any  health  officer  may  suddenly 
be  confronted  with  the  disease. 

Examination  for  Vibrios. — A  diagnosis  of  cholera  is  made  by 
finding  its  vibrios  in  the  intestinal  discharges.  They  grow  read- 
ily in  a  medium  which  is  so  strongly  alkaline  that  it  restrains 
the  growth  of  other  intestinal  organisms.  A  liquid  alkaline 
medium  of  peptone  or  egg-water  is  inoculated  with  discharges 
from  the  suspected  person.  If  cholera  vibrios  are  present,  they 
will  grow  on  the  surface  of  the  medium.  They  are  identified  by 
agglutination  tests.  When  cholera  appears  among  a  number  of 
persons  who  are  closely  associated,  as  on  shipboard,  there  are 
usually  a  number  of  healthy  carriers,  and  the  only  way  to  detect 
them  is  to  examine  the  intestinal  discharges  of  every  person. 

A  cholera  vaccine  is  used  for  preventive  inoculation,  and  a 
serum  for  treatment,  but  with  varying  success. 

If  a  health  officer  suspects  a  case  to  be  cholera,  it  is. his  duty 
to  quarantine  the  person  and  request  prompt  assistance  from  the 
State  Department  of  Health. 


CHAPTER  XXV 

INFECTIONS  OF  THE  CENTRAL  NERVOUS  SYSTEM 

Infections  of  the  brain  and  spinal  cord  may  occur  with  a 
number  of  different  kinds  of  bacteria,  among  which  are  strepto- 
cocci, pneumococci,  tubercle  bacilli,  and  influenza  bacilli;  but 
the  diseases  caused  by  these  germs  do  not  occur  in  epidemics. 
Two  diseases  which  do  occur  in  epidemics  are  epidemic  cerebro- 
spinal meningitis  and  anterior  poHomyelitis. 

EPIDEMIC  CEREBROSPINAL  MENINGITIS 

Epidemic  meningitis  is  an  inflammation  of  the  brain  and 
spinal  cord.     Pus  is  formed  in  the  meninges,  and  the  spinal 


CARRIER 


Fig.  15. — Method  of  transmission  of  meningitis  and  poliomyelitis. 

fluid  is  cloudy  and  increased  in  amount.  The  disease  is  caused 
by  a  specific  bacterium  called  the  Meningococcus  intracelhdaris. 
The  cocci  are  found  in  the  spinal  fluid,  the  nasal  secretions,  and 
the  urine.  They  also  exist  in  the  Wood  during  the  first  week 
or  two  of  the  disease.  Healthy  carriers  have  the  cocci  in  the 
nose  and  pharynx.     The  disease  is  spread  by  contact  through 

267 


268  THE  HEALTH   OFFICER 

the  transference  of  nasal  secretions.  Scattered  cases  are  fre- 
quent and  epidemics  of  the  disease  sometimes  develop. 

While  the  principal  seat  of  a  meningococcic  infection  is 
usually  the  spinal  cord,  there  may  also  be  a  general  infection  of 
the  blood.  There  are  also  cases  of  a  general  infection  or  septi- 
cemia due  to  meningococci  in  the  blood  with  few  or  none  of  the 
cocci  in  the  spinal  cord. 

Recognition. — All  forms  of  meningitis  give  general  signs  of 
irritation  of  the  brain  and  spinal  cord.  There  are  fever,  irri- 
tability, twitchings  of  the  muscles,  rigidity  of  the  neck  and  back, 
and  often  convulsions.     These  signs  indicate  meningitis  in  some 


Fig.  16. — Method  of  holdin.c;  a  child  for  spinal  puncture. 

form,  and  it  is  the  duty  of  the  health  officer  to  determine  whether 
or  not  an  infectious  type  of  the  disease  is  present.  A  skin 
eruption  may  be  present,  and  from  this  fact  the  disease  is  some- 
times called  spotted  fever.  Symptoms  resembling  those  of  epi- 
demic meningitis  may  be  present  in  meningismus,  which  is  an 
irritation  of  the  brain  and  spinal  cord  occurring  during  the  course 
of  any  disease,  especially  pneumonia.  The  same  symptoms 
may  occur  in  poliomyelitis,  tubercular  meningitis,  and  menin- 
gitis caused  by  other  organisms,  such  as  pneumococci.  A  diag- 
nosis between  these  conditions  cannot  always  be  made  by  the 


INFECTIONS   OF   THE   CENTRAL   NERVOUS   SYSTEM  269 

clinical  symptoms.  The  only  certain  method  of  recognizing  the 
diseases  is  by  means  of  a  spinal  puncture  and  the  examina- 
tion of  the  fluid  that  is  drawn. 

Meningitis  may  also  be  caused  by  the  organism  of  mumps. 
This  form  may  be  recognized  by  the  presence  of  the  signs  of 
mumps  and  the  absence  of  bacteria  in  the  spinal  fluid. 

Spinal  Puncture. — This  is  a  surgical  operation,  and  is  to  be 
done  with  all  the  precautions  of  surgical  antisepsis.  The  opera- 
tion is  not  difficult  for  anyone  who  is  expert  in  minor  surgery. 
No  anesthetic  is  required.  The  best  position  for  the  patient  is 
lying  upon  the  side  with  the  body  bent  forward  as  much  as  pos- 
sible in  order  to  open  the  spaces  between  the  vertebrae.  If  the 
patient  is  a  child,  an  assistant  lays  it  across  his  lap  upon  its  side 
with  its  face  looking  backward,  grasps  its  neck  and  shoulders 
with  one  hand  and  the  knees  with  the  other,  and  forcibly 
flexes  its  whole  body.  The  puncture  is  made  just  below  the 
lower  end  of  the  spinal  cord.  A  hypodermic  needle  may  be 
used,  but  the  best  instrument  is  a  long,  slim  trocar  or  needle  made 
especially  for  the  purpose.  The  point  of  entrance  of  the  needle 
is  immediately  below  the  spine  of  the  vertebra  that  is  nearest  a 
line  connecting  the  crests  of  the  ilium.  The  skin  is  sterilized 
with  iodin,  and  the  needle  is  thrust  forward  and  slightly  upward 
to  a  depth  of  from  1  to  3  inches,  according  to  the  age  and  de- 
velopment of  the  patient.  Entrance  into  the  spinal  canal  is 
indicated  by  a  sudden  loss  of  the  feeling  of  resistance  and  by  a 
flow  of  spinal  liquid.  The  spinal  fluid  will  run  out  drop  by  drop 
from  a  normal  cord,  but  in  a  stream  if  it  is  under  pressure. 
About  a  teaspoonful  will  flow  normally,  but  1  or  2  ounces  may 
flow  if  disease  is  present.  A  sample  is  caught  in  a  sterile  bottle 
and  sent  to  a  laboratory  for  examination.  The  fluid  may  some- 
times be  bloody  on  account  of  puncturing  a  vein. 

Examination  of  the  Spinal  Fluid. — An  examination  of  a 
spinal  fluid  consists  of  a  cell  count,  a  bacteriologic  test,  and  a 
chemical  analysis.  The  cell  count  and  chemical  analysis  have 
little  value  when  the  fluid  is  bloody. 

The  cells  in  a  spinal  fluid  consist  of  leukocytes  or  white  blood- 
cells.  They  are  counted  by  means  of  an  ordinary  blood-count- 
ing apparatus.  A  normal  spinal  fluid  usually  contains  from  10 
to  20  cells  per  cubic  millimeter,  and  is  clear  and  colorless. 

The  bacteria  in  a  spinal  fluid  are  determined  by  a  direct 
examination  of  the  fluid  and  by  cultures.  Finding  a  specific 
organism,  such  as  the  meningococcus  or  streptococcus,  fixes  the 
diagnosis. 

The  usual  chemical  analysis  of  a  spinal  fluid  are  those  for 
albumin,  for  globulin,  and  for  the  reduction  of  Fehling's  solu- 


270  THE   HEALTH    OFFICER 

tion.  Albumin  or  globulin,  in  the  absence  of  blood  in  the 
spinal  fluid,  indicates  inflammation.  The  absence  of  the  re- 
duction of  Fchling's  solution  points  strongly  to  tuberculous 
meningitis. 

The  spinal  fluid  in  epidemic  meningitis  contains  so  many 
cells  that  it  is  cloudy,  and  may  properly  be  called  pus.  If  a 
spinal  fluid  is  cloudy,  the  disease  is  much  more  hkely  to  be 
epidemic  meningitis  than  any  other  disease.  A  stained  micro- 
scopic specimen  of  fluid  from  a  case  will  show  the  characteristic 
cocci  of  the  disease.  If  Gram-negative  diplococci  are  found  in 
a  cloudy  fluid,  the  disease  may  be  considered  to  be  epidemic 
cerebrospinal  meningitis,  for  the  other  bacteria  which  produce  a 
cloudy  fluid,  especially  streptococci  and  pneumococci,  are  Gram- 
positive. 

Serum  Treatment. — Killed  meningococci  injected  into  horses 
give  rise  to  an  abundance  of  antibodies  which  act  directly  upon 
meningococci  with  which  they  come  in  contact.  The  serum  of 
the  injected  horses  is  successfully  used  in  the  treatment  of  epi- 
demic meningitis  in  human  beings.  A  spinal  puncture  is  made, 
and  the  serum  is  slowly  injected  in  an  amount  slightly  less  than 
the  quantity  of  the  fluid  that  is  withdrawn.  The  amount  is 
usually  from  15  to  30  c.c.  in  an  adult.  Usually  six  doses  are 
gi\'en  on  successive  days.  It  is  well  to  have  the  serum  ready 
and  to  inject  it  at  the  time  of  making  the  first  diagnostic  puncture 
if  the  fluid  is  cloudy.  The  State  Department  of  Health  of  New 
York  State  supplies  antimeningitis  serum  to  health  officers  free 
of  charge.  There  are  several  subvarieties  of  meningococci;  and 
a  serum  is  potent  against  only  those  varieties  with  which  it  was 
produced.  There  is  no  practical  method  of  determining  the  t}pe 
of  meningococci  present  in  a  case  in  time  to  be  of  value  in  choos- 
ing the  proper  serum.  The  serum  supplied  by  the  New  York 
State  Department  of  Health  is  made  from  several  of  the  most 
common  varieties.  Since  meningococci  may  be  present  in  the 
blood,  it  is  a  standard  procedure  to  give  the  antimeningococcic 
serum  intravenously  as  weU  as  intraspinally. 

Management  of  a  Case. — Epidemic  meningitis  spreads  by 
contact  with  the  excretions  of  the  nose  and  mouth,  and  the 
principal  precautions  are  directed  against  those  excretions.  Iso- 
lation, cleanliness,  and  the  destruction  of  the  excretions  are  neces- 
sary in  every  case.  The  precautions  are  about  the  same  as  in 
diphtheria  fsee  page  216). 

Epidemiology. — Epidemic  meningitis  is  a  reportable  disease 
in  New  York  and  many  other  states.  It  is  the  duty  of  a  phy- 
sician to  report  every  case  that  shows  signs  of  meningitis,  and 
to  take  advantage  of  the  means  for  diagnosis  and  treatment 


INFECTIONS    OF   THE   CENTRAL   NERVOUS    SYSTEM  27] 

that  the  health  officer  has  at  his  command.  ^Fhe  recognition  of 
cases  is  essential  in  the  control  or  prevention  of  an  epidemic  of 
the  disease.  There  are  often  from  five  to  ten  carriers  to  every 
known  case.  The  carrier  problem  in  meningitis  is  about  the 
same  that  it  is  in  diphtheria. 

Carriers  are  detected  by  means  of  cultures  taken  from  the 
nasopharynx.  The  bacilli  die  quickly  when  they  are  chilled  or 
dried,  and  so  the  culture-media  must  be  inoculated  at  the  time 
that  the  culture  is  taken.  Curve  the  end  of  a  sterile  swab 
upward,  pass  it  behind  the  soft  palate,  and  rotate  it  against  the 
back  of  the  pharynx.  Remove  it  and  rub  it  lightly  over  the 
surface  of  the  culture-media  in  a  Petri  dish.  Keep  the  dish 
warm  by  means  of  a  bottle  of  warm  water  carried  in  the  container, 
and  take  it  to  the  laboratory  as  soon  as  possible.  Taking  a 
culture  and  inoculating  the  culture-media  require  some  skill, 
which  a  health  officer  can  readily  acquire  by  observing  an  experi- 
enced operator.  The  rule  is  to  isolate  a  carrier  until  two  negative 
cultures  have  been  obtanied  on  successive  days. 

Tubercular  Meningitis. — A  meningitis  due  to  tubercle  bacilli 
frequently  occurs.  It  has  a  gradual  onset  with  an  irregular 
fever,  and  projectile  vomiting  is  usually  present.  The  patient 
falls  into  a  coma  from  which  it  is  aroused  only  with  great 
difficulty;  the  spinal  fluid  is  clear  but  increased  in  amount; 
the  cell  count  is  increased;  and  the  case  slowly  progresses  to 
death. 

Meningitis  Due  to  Other  Causes.— A  meningitis  due  to 
streptococci,  pneumococci,  and  other  organisms  gives  signs  and 
symptoms  similar  to  those  of  epidemic  meningitis.  Frequently  a 
middle-ear  disease  or  an  injury  may  produce  the  infection.  The 
diagnosis  is  made  by  finding  the  specific  bacteria  in  the  spinal 
fluid. 

Differential  Diagnosis. — When  symptoms  arise  suggesting  an 
infection  of  the  central  nervous  system,  the  health  officer  must 
bear  in  mind  the  various  conditions  and  diseases  that  may  pro- 
duce them.  He  must  consider  the  tjrpical  signs  of  the  various 
diseases,  and  balance  them  with  the  findings  of  the  examination 
of  the  spinal  fluid.  A  correct  diagnosis  is  difficult  in  isolated 
cases,  and  a  health  officer  is  justified  in  asking  for  expert  assist- 
ance in  doubtful  cases. 

POLIOMYELITIS 

Nature  of  the  Disease. — Anterior  poliomyelitis,  or  infantile 
paralysis,  is  caused  by  a  virus  which  will  pass  through  a  porcelain 
filter.  It  may  be  grown  in  culture-media,  and  when  it  is  so 
grown,   extreme^  small  cocci  hke  streptococci  may  be  seen; 


272  THE   HEALTH   OFFICER 

but  the  visible  forms  have  not  been  positively  identified  as  larger 
forms  of  the  invisible  germs. 

Poliomyelitis  germs  produce  a  general  poisoning,  or  toxemia, 
of  the  whole  body,  as  is  shown  by  a  fever  and  general  sickness. 
There  is  also  a  local  effect  on  the  central  nervous  system  depend- 
ing on  the  amount  and  virulence  of  the  toxins.  A  mild  poison- 
ing may  give  only  slight  signs  of  irritation  of  the  brain  and 
spinal  cord  which  soon  pass  off".  A  poisoning  that  is  more 
severe  or  long  continued  may  produce  a  weakness  of  the  cells 
of  the  central  nervous  system,  especially  of  groups  of  motor 
cells  in  the  spinal  cord,  and  is  shown  by  a  loss  of  reflexes,  and  by 
paralysis  which  may  be  transient  or  permanent,  according  to  the 
degree  of  the  injury  to  the  nerve-cells.  The  degree  of  sickness 
may  vary  from  a  slight,  unnoticed  fever  to  a  paralysis  of  all  the 
muscles  of  the  body,  and  death. 

The  poliomyelitis  virus  is  contained  in  the  substance  of  the 
spinal  cord  and  in  the  excretions  of  the  nose.  Poliomyelitis 
may  be  readily  transmitted  to  monkeys  by  spraying  the  infective 
material  into  the  animal's  nose;  less  readily  by  injecting  it  into 
the  spinal  canal ;  and  only  with  difficulty  by  its  injection  into  the 
blood.  The  course  of  the  disease  in  monkeys  is  almost  exactly 
similar  to  that  in  human  beings.  The  fact  that  poliomyehtis 
may  exist  in  a  mild  form  of  what  appears  to  be  a  simple  fever 
has  been  established  by  animal  ex-perimentation. 

Poliomyelitis  has  frequently  occurred  in  mild  epidemics  in 
which  the  death-rate  was  only  2  or  3  per  cent.;  but  in  1916  an 
epidemic  spread  from  New  York  City  as  a  center,  involved  about 
20,000  cases,  and  had  a  death-rate  of  about  25  per  cent.  This 
is  an  example  of  an  old  disease  suddenly  developing  a  \irulence 
and  infectiousness  that  had  never  before  been  observed.  Every 
health  officer  must  keep  the  possibility  of  the  disease  in  mind 
hereafter. 

Recogmtion. — Poliomyelitis  produces  a  fever  which  usually 
has  a  sudden  onset,  often  with  vomiting.  After  a  day  or  two 
there  is  a  remission  of  the  fever,  soon  followed  by  its  return. 
This  remission  and  return  of  the  fever  without  definite  signs  of 
other  sickness  is  a  fairly  constant  and  reliable  s}Tnptom  of 
poliomyelitis. 

Poliomyelitis  usually  causes  a  headache  and  backache  and  a 
tenderness  of  the  muscles.  The  pain  and  tenderness  are  marked 
in  the  nerves  as  they  pass  out  from  the  spinal  cord,  and  in  order 
to  avoid  pressure  on  them  the  patient  instinctively  holds  the 
head  and  spine  bent  backward  and  resists  attempts  to  bend  them 
forward.  Kernig's  sign  is  resistance  to  straightening  the  knee 
when  the  leg  is  flexed  on  the  abdomen,  and  is  due  to  the  tender- 


INFECTIONS   OF   THE   CENTRAL  NERVOUS   SYSTEM  273 

ness  of  the  spinal  nerves.  An  evident  distress  on  bending  the 
neck  and  body  forward  is  a  sign  that  is  strongly  suggestive  of 
poliomyelitis.  If  it  is  entirely  absent,  the  case  is  probably  not 
poliomyelitis. 

The  muscular  reflex  of  the  knee  is  often  impaired  in  polio- 
myelitis, although  it  may  be  increased  during  the  period  of 
irritation  which  precedes  paralysis. 

A  paralysis  of  any  part  of  an  arm  or  leg  or  the  face  following 
a  fever  is  suggestive  of  poliomyelitis.  The  paralysis  may  be 
only  slight  and  may  be  evident  only  when  the  patient  cries  or 
throws  its  limbs  about.  It  does  not  exist  in  many  cases  which 
are  undoubtedly  poliomyelitis.  A  paralysis  of  an  arm  or  leg  is 
often  preceded  by  a  twitching  of  the  muscles  of  the  part,  and  if 
it  is  observed,  paralysis  may  be  expected. 

Spinal  Puncture. — Changes  in  the  spinal  fluid  are  nearly 
always  found  in  poliomyelitis.  It  is  the  duty  of  the  physician 
and  health  officer  to  have  a  spinal  puncture  done  and  an  exam- 
ination of  the  fluid  made  whenever  the  two  signs  of  the  typical 
course  of  a  fever  and  the  tenderness  and  rigidity  of  the  neck  are 
present;  but  if  the  two  signs  are  accompanied  by  a  paralysis, 
a  spinal  puncture  may  not  be  necessary  for  a  diagnosis.  A 
persistent  loss  of  the  knee  reflex  usually  indicates  paralysis. 

The  spinal  fluid  in  poliomyelitis  is  increased  in  amount,  is 
clear  and  colorless,  and  the  number  of  its  cells  is  increased.  If 
50  cells  per  cubic  millimeter  are  found,  the  case  may  be  con- 
sidered to  be  poliomyelitis,  provided  there  are  no  eNddent  signs 
of  other  spinal  cord  disease,  such  as  tetanus.  The  number  of 
cells  may  run  into  the  hundreds  and  thousands. 

Groups  of  Cases. — There  are  three  broad  groups  of  polio- 
myelitis cases  which  a  health  officer  must  keep  in  mind.  The 
first  group  consists  of  those  which  show  a  t>^ical  paralysis. 
These  cases  are  plain  and  e\ddent,  and  were  the  only  ones  that 
were  formerly  recognized. 

The  second  group  of  cases  is  composed  of  those  in  which  the 
disease  seems  to  be  seated  in  the  brain,  and  the  symptoms  are 
those  of  meningitis.  These  cases  were  formerly  called  menin- 
gitis, and  many  cases  are  still  mistaken  for  that  disease. 

The  cases  belonging  to  the  third  group  are  those  in  which 
there  is  no  paralysis  or  other  severe  symptom.  These  are  often 
called  abortive  cases.  They  were  formerly  entirely  unrecog- 
nized and  unsuspected;  but  a  typical  onset  and  course  of  the 
fever  and  a  stiffness  of  the  neck  are  present  in  these  cases,  and 
the  disease  may  be  recognized  by  a  careful  observation. 

Skin  Rash. — An  eruption  of  the  skin  sometimes  occurs  dur- 
ing poliomyeUtis,  and  may  be  mistaken  for  measles  or  scarlet 

i8 


274  THE   HEALTH    OFFICER 

fever.  It  may  be  in  small  patches  or  may  cover  extensive  areas. 
Health  officers  who  are  ignorant  of  the  possibility  of  the  erup- 
tion are  needlessly  alarmed  when  they  see  it. 

Serum  Treatment. — Persons  who  have  had  poliomyelitis  are 
immune  to  the  disease  during  the  rest  of  their  Hves,  and  their 
blood-serum  may  contain  protective  antibodies.  The  Depart- 
ments of  Health  of  the  City  and  State  of  New  York  advise  the 
use  of  human  immune  serum  in  the  treatment  of  cases  if  it  can 
be  obtained.  The  serum  is  given  in  the  same  manner  and  quan- 
tity as  meningitis  serum. 

Epidemiology. — SusceptibiUty  to  the  virus  of  poliomyelitis  is 
not  great,  and  the  disease  was  not  recognized  as  communicable 
until  experiments  on  monkeys  in  1911  proved  its  infectiousness. 
During  the  1916  epidemic  an  exposure  to  previously  known  cases 
could  be  traced  about  as  frequently  as  in  an  epidemic  of  scarlet 
fever.  Poliomyelitis  spreads  by  means  of  the  excretions  of  the 
nose  and  throat.  The  period  of  incubation  seems  to  be  about 
one  week.  There  are  healthy  carriers  of  the  germs,  but  patients 
who  have  recovered  from  the  disease  seem  to  become  free  from 
the  germs  within  a  month  or  six  weeks  after  the  beginning  of  the 
sickness. 

The  control  of  poliomyelitis  requires  a  strict  quarantine  of 
the  sick  persons  and  their  premises  for  at  least  three  weeks  from 
the  onset  of  the  fever,  the  disinfection  and  proper  disposal  of 
all  excretions,  and  the  exclusion  of  flies  from  the  sick  room. 
If  the  disease  is  epidemic,  the  board  of  health  may  require  the 
isolation  and  medical  supervision  of  all  children  under  sixteen 
years  of  age  coming  from  the  infected  districts,  and  may  forbid 
all  gatherings  of  children.  If  the  epidemic  involves  more  than 
one  state,  the  United  States  Public  Health  Service  may  institute 
a  medical  supervision  of  all  children  traveling  from  one  state  to 
another.  These  measures  may  seem  harsh  and  crude,  but  they 
are  justified  until  we  have  more  exact  knowledge  of  the  virus 
and  of  the  manner  of  its  spread. 

A  great  difficulty  in  poliomyelitis  prevention  is  the  detection 
of  cases.  It  is  a  reportable  disease  in  most  states,  but  many 
physicians  fail  to  recognize  the  disease  or  to  suspect  it  unless 
paralysis  is  present.  If  a  diagnosis  is  in  doubt,  it  is  the  duty  of 
the  health  officer  to  ask  for  the  assistance  of  the  State  Depart- 
ment of  Health.  A  poliomyelitis  epidemic  is  a  severe  test  of  a 
health  ofificer's  diagnostic  acumen  and  of  his  ability  to  secure  the 
co-operation  of  physicians. 

After-care  of  Paralyzed  Cases. — After  an  epidemic  of  polio- 
myelitis has  passed,  there  will  be  a  number  of  cases  of  paralysis 
which   will   require    treatment   for   months   and   years.     Good 


INFECTIONS    OF    THE    CENTRAL   NERVOUS    SYSTEM 


275 


results  that  were  formerly  supposed  to  be  impossible  may  be 
obtained  by  training  the  affected  muscles.  One  procedure  that 
is  of  great  value  in  every  case  is  complete  rest  of  the  affected 
muscle.  This  advice  is  directly  opposite  to  that  formerly  given 
■ — to  exercise  the  paralyzed  part  as  much  as  possible.  Exercise 
stretches  and  tires  the  muscles  beyond  recovery,  but  the  rest 
treatment  ahows  the  muscles  and  the  nerve-cells  to  regain  their 
nutrition  and  strength.  For  example,  a  child  with  paralyzed 
muscles  of  the  calf  of  the  leg  is  kept  off  its  feet  for  weeks.  Its 
leg  is  exercised  for  only  a  moment  on  each  day  at  first,  and  the 
exercises  are  increased  as  strength  returns.     The  treatment  is 


Fig.  17. — Testing  muscular  strength  at  a  poliomyelitis  after-care  clinic. 

slow  and  tedious,  but  the  results  in  most  cases  are  useful  muscles 
and  ability  to  use  the  hmbs. 

The  Departments  of  Health  of  Vermont  and  New  York 
conduct  clinics  and  supervise  the  after-care  of  cases  in  their 
homes.     The  procedure  with  each  case  at  a  clinic  is  as  follows: 

1.  Test  each  group  of  muscles  and  make  an  accurate  estimate 
of  the  strength  of  each  group. 

2.  Prescribe  the  exact  method  and  amount  of  rest,  massage, 
and  exercise  which  is  required.  This  prescription  is  as  definite 
as  a  prescription  for  a  medicine  to  be  taken  for  rheumatism. 

3.  Advise  the  family  physician  regarding  the  plaster  casts  and 
braces  that  are  needed,  and  take  exact  measurements  for  the 
braces. 


276 


THE   HEALTH    OFFICER 


Public  health  nurses  visit  the  cases  in  their  homes  and 
instruct  the  mothers  in  the  proper  methods  of  carrying  out  the 
treatment.  The  after-care  must  be  continued  for  months  or 
years. 

TETANUS 

The  Bacilli. — Tetanus,  or  lockjaw,  is  caused  by  a  bacterium 
which  often  grows  in  the  intestines  of  horses.  The  bacilli  are 
found  in  the  soil  of  streets  and  cultivated  fields  which  contain 
the  excretions  of  the  animals.  It  probably  does  not  multiply  in 
the  soil,  but  it  exists  in  the  form  of  spores  which  are  not  easily 
killed.  The  spores  enter  the  human  body  by  means  of  wounds 
which  are  contaminated  with  soil.  The  bacilli  are  anaerobic, 
and  cannot  grow  except  in  the  absence  of  oxygen;  but  they  are 
likely  to  grow  in  wounds  into  which  oxygen  cannot  penetrate, 


HORSe    exCRlTIONS 


Fig.  18. — Method  of  transmission  of  tetanus. 


such  as  puncture  wounds  made  by  stepping  on  nails  and  those 
made  by  fireworks.  The  period  of  incubation  of  tetanus  is 
usually  from  one  to  two  weeks.  The  toxin  of  tetanus  travels 
from  the  site  of  growth  of  the  germs  through  the  nerves  and  enters 
the  nerve-cells  of  the  spinal  cord  and  irritates  them,  producing 
contractions  of  the  muscles  and  convulsions.  A  diagnosis  of 
tetanus  is  made  by  a  stiffness  of  the  neck  and  an  inability  to 
open  the  mouth.  A  chill  and  fever  usually  accompany  the  stiff- 
ness, and  there  is  usually  a  history  of  a  wound  or  a  severe 
bruising,  or  a  burn. 

Antitoxin.— The  injection  of  tetanus  bacilli  into  horses  causes 
them  to  form  an  antitoxin  which  is  used  for  the  prevention  and 
treatment  of  tetanus  in  human  beings.  It  is  manufactured  in 
the  same  manner  as  diphtheria  antitoxin.     The  preventive  dose 


INFECTIONS   OF   THE   CENTRAL  NERVOUS   SYSTEM  277 

for  an  adult  person  is  1000  or  1500  units  given  subcutaneously  as 
soon  as  possible  after  a  contaminated  wound  is  received,  and 
repeated  in  two  weeks  if  the  wound  has  not  healed  at  that  time. 

The  curative  dose  of  tetanus  antitoxin  is  from  10,000  to 
20,000  units  given  intraspinally  in  the  same  manner  that  menin- 
gitis serum  is  given.  If  the  antitoxin  is  given  intravenously  or 
subcutaneously,  it  travels  to  the  spinal  cord  too  slowly  to  be  of 
much  benefit,  but  if  it  is  introduced  directly  into  the  spinal 
canal,  it  will  reach  the  toxin  in  the  nerve-cells  within  a  short 
time.  If  antitoxin  is  given  intraspinally  in  the  first  day  or  two 
after  the  first  symptoms  of  tetanus,  nearly  all  the  patients  will 
recover.  It  is  also  of  great  value  when  it  is  given  later  in  the 
disease.  It  is  necessary  to  treat  the  original  wound  and  to 
remove  all  foreign  Substances  which  contaminate  it. 

The  New  York  State  Department  of  Health  distributes  teta- 
nus antitoxin  to  health  officers  in  both  preventive  and  curative 
doses,  and  advises  that  it  be  used  for  immunization  after  every 
suspicious  wound. 

A  health  officer  need  not  isolate  a  case  of  tetanus  or  disinfect 
the  excretions  of  the  patient.  The  prevention  of  the  disease 
consists  in  treating  all  wounds  according  to  the  rules  of  anti- 
septic surgery,  and  in  giving  immunizing  doses  of  antitoxin  to 
all  who  have  wounds  in  which  the  tetanus  germs  are  likely  to 
grow, 

RABIES 

The  Virus. — Rabies,  or  hydrophobia,  is  an  infectious  disease 
which  is  now  rarely  seen  in  human  beings,  although  it  frequently 


omecT 


&06  HUMAN 


Fig.  19. — Method  of  transmission  of  rabies. 

occurs  in  dogs  and  cats.  It  is  caused  by  a  filterable  virus  which 
is  found  in  the  central  nervous  system  and  in  the  saliva  of  af- 
fected dogs  and  cats,  and  is  introduced  into  the  human  body  by 
means  of  wounds  made  with  the  teeth  of  rabid  animals.  The 
incubation  period  of  the  disease  is  extremely  variable,  but  in 


278  THE   HEALTH    OFFICER 

human  beings  it  is  from  two  weeks  to  six  months.  The  symp- 
toms of  the  sickness  in  human  beings  are  spasms  and  convul- 
sions beginning  in  the  muscles  of  swallowing.  After  the  disease 
has  developed,  it  always  ends  in  the  death  of  the  patient. 

Recognition. — Rabies  is  a  common  disease  of  dogs  in  some 
parts  of  the  United  States,  and  an>-  health  otiicer  may  suddenly 
be  called  to  deal  with  an  atTected  animal.  The  disease  may  be 
suspected  when  a  dog  or  cat  is  sick  and  shows  unusual  irritabil- 
ity. A  rabid  dog  or  cat  is  likely  to  attack  and  infect  other  ani- 
mals that  approach  it.  If  a  dog  or  cat  shows  suspicious  s^-mp- 
toms,  confine  it  in  a  quiet  place  where  it  cannot  bite  another 
animal  or  a  person.  If  it  has  rabies,  it  will  die  within  a  very  few 
days.  If  it  recovers,  it  has  not  had  rabies.  If  the  animal  dies 
or  is  killed,  cut  off  the  head,  preserve  it  on  ice,  and  send  it  to  a 
laboratory  for  an  examination  of  the  brain  in  order  to  make  the 
diagnosis  certain. 

Negri  Bodies. — A  diagnosis  of  rabies  may  be  made  by  finding 
Negri  bodies  in  the  brain  cells.  A  small  piece  of  gray  matter  is 
crushed  upon  a  microscopic  sHde  and  stained.  The  Negri  bodies 
appear  as  spheres  approximately  the  size  of  red  blood-cells  located 
in  the  nerve-cells.  If  suspicious  bodies  are  seen,  animal  inocula- 
tion tests  with  the  brain  tissue  will  produce  the  disease  when  the 
animal  has  rabies. 

The  nature  of  the  Negri  bodies  is  in  doubt.  They  may  be 
the  specific  organisms  of  the  disease,  or  bodies  produced  by  a 
poisoning  of  the  nerve-cells. 

Preventive  Inoculations. — The  subcutaneous  injection  of  the 
virus  of  rabies  from  a  rabbit  into  a  human  being  produces  an 
immunity  which  lasts  for  a  few  months.  The  injections  are 
used  in  order  to  prevent  the  development  of  rabies  in  a  person 
who  has  been  bitten  by  a  rabid  dog.  They  constitute  the  Pasteur 
preventive  treatment.  The  material  used  is  the  spinal  cord  of 
a  rabbit  that  is  paralyzed  with  rabies.  The  cord  is  removed 
and  hung  in  a  bottle  over  sticks  of  caustic  potash.  The  dose  is 
about  2  cm.  of  a  cord  emulsified  with  glycerin.  The  first  injec- 
tion is  made  from  a  cord  that  has  been  hung  for  eight  days, 
during  which  time  its  virus  has  become  weakened  and  nearly 
killed.  The  time  during  which  the  cords  are  hung  is  progres- 
sively lessened  until  an  emulsum  of  an  almost  fresh  cord  is  used. 
The  whole  series  of  injections  cover  a  period  of  three  weeks. 

The  material  for  the  injections  may  be  obtained  by  mail 
daily  from  the  United  States  Public  Health  Service  in  Washing- 
ton. The  Departments  of  Health  of  New  York  State  and  the 
city  of  New  York  also  supply  the  material  through  the  health 
oflScers,  all  of  whom  are  expected  to  know  where  to  obtain  the 


INFECTIONS    OF   THE   CENTRAL  NERVOUS    SYSTEM  279 

virus,  and  to  use  it  on  every  person  who  has  been  bitten  by  a 
rabid  animal. 

When  a  person  is  bitten,  the  virus  grows  and  spreads  slowly. 
It  may  be  killed  by  cauterizing  the  wound  to  its  bottom  with 
strong  nitric  acid.  Other  preventive  measures  against  rabies 
are  the  muzzling  of  dogs  on  highways  and  catching  and  killing 
all  stray  dogs  and  cats.  A  dog-catcher  is  an  important  official 
on  the  staff  of  every  board  of  health.  If  a  dog  is  supposed  to 
have  been  bitten,  the  proper  measure  to  take  is  to  confine  the 
animal  for  three  weeks,  or  the  period  of  incubation  in  a  bitten 
animal.  If  it  does  not  develop  the  disease  within  that  time,  it 
probably  has  escaped  infection. 

The  power  of  capturing  and  controlling  rabid  animals  in 
New  York  State  is  vested  in  the  Commissioner  of  Agriculture. 
He  may  institute  a  quarantine  of  a  particular  district  and  may 
empower  the  sheriff  to  execute  his  orders  (Agricultural  Law, 
Sec.  96). 


CHAPTER  XXVI 

VENEREAL  DISEASES 

A  Public  Health  Problem. — The  two  diseases  that  are  usually 
classed  as  venereal  are  gonorrhea  and  s\philis.  A  third  one  of 
less  importance  is  chancroid.  Their  specific  micro-organisms 
are  given  off  from  open  lesions  upon  the  skin  or  the  mucous  mem- 
branes. Each  disease  is  produced  by  the  entrance  of  discharges 
from  an  infected  person  directly  into  an  open  wound  upon  the 
skin  or  mucous  membrane,  or  through  the  mucous  membrane  at 
an  orifice  of  the  body. 

There  has  been  a  popular  belief  that  a  venereal  disease  is  of 
merely  temporary  importance,  and  concerns  only  the  person  who 
is  infected.  There  is  often  little  discomfort  or  gross  evidence 
of  sickness.  The  severer  s>Tnptoms  often  subside  promptly, 
and  the  patient  may  be  able  to  mingle  with  society  without  excit- 
ing suspicion.  But  the  specific  germs  often  remain  in  unhealed 
and  unnoticed  lesions,  and  are  transmitted  to  innocent  persons, 
especially  to  a  wife  by  an  uncured  husband.  The  germs  that 
remain  in  the  body  may  produce  severe  forms  of  diseases  months 
or  years  after  apparent  recovery.  Many  cases  of  rheumatism 
and  bone  disease,  a  quarter  of  all  cases  of  insanity,  many  severe 
gynecologic  conditions,  and  all  cases  of  locomotor  ataxia  and 
paresis  are  late  manifestations  of  uncured  venereal  disease. 
Grave  effects  are  left  in  probably  10  per  cent,  of  all  cases.  Ve- 
nereal diseases  are  plagues  which  rank  with  tuberculosis  in  their 
prevalence  and  in  their  evil  effects  on  individuals  and  society. 
They  are  both  curable  and  preventable,  and  their  control  is  a 
public  health  problem  which  concerns  every  health  officer  and 
physician. 

Chancroi'd  is  an  ulceration  caused  by  bacterial  infection.  It 
is  usually  located  upon  an  external  sexual  organ,  but  it  may 
occur  upon  any  other  part  of  the  body.  It  may  cause  enlarge- 
ments and  abscesses  of  the  neighboring  lymph-nodes.  Its  af- 
fects are  usually  local,  and  resemble  those  of  a  streptococcus 
infection.  It  is  important  to  a  health  officer  chiefly  because  it 
may  resemble  a  syphilitic  sore.  A  diagnosis  may  be  made  by 
examining  the  scraping  from  the  ulcer  with  a  microscope.  If 
the  sore  is  s>TDhiUtic,  the  characteristic  spirilli  of  syphilis  may  be 
found. 

280 


VENEREAL  DISEASES  281 

Gonorrhea  is  caused  by  a  diplococcus  called  the  gonococcus 
or  the  Micrococcus  gonorrhoeae.  The  germs  nearly  always  enter 
the  body  through  the  genito-urinary  tract  or  the  eye.  The  in- 
cubation period  is  usually  about  four  days,  but  it  varies  from  one 
up  to  eight  days.  The  bacteria  grow  among  the  epithelial  cells 
of  the  mucous  membrane  at  the  point  of  entrance,  and  produce 
an  acute  inflammation  with  a  discharge  of  pus.  They  may 
destroy  the  epithehum  and  produce  ulcerations  which  lead  to 
strictures  or  blindness  on  healing.  The  germs  may  remain  alive 
and  dormant  in  the  unhealed  ulcers,  and  may  regain  their  original 
virulency  when  they  are  transferred  to  another  person.  Those 
in  whom  evidences  of  the  disease  remain  are  usually  carriers  of 
virulent  germs. 

Gonococci  may  enter  the  blood-stream  and  produce  septi- 
cemia, or  endocarditis,  or  an  inflammation  of  the  joints  which 
may  persist  for  weeks.  They  may  enter  the  peritoneum  and 
produce  peritonitis  or  abscesses.  Many  cases  of  peritonitis  in 
married  women  are  caused  by  gonococci  which  are  derived  from 
the  uncured  disease  of  their  husbands.  The  disease  is  the  cause 
of  most  cases  of  steriHty  by  closing  either  the  spermatic  tubes 
in  the  male  or  the  fallopian  tubes  in  the  female.  Gonorrheal 
ophthalmia  is  the  principal  cause  of  blindness  in  children.  The 
crippling  effects  of  the  chronic  forms  of  the  disease  and  the 
damaging  results  of  the  acute  forms  are  more  common  than 
are  popularly  supposed,  for  physicians  often  conceal  the  true 
nature  of  the  disease  by  calling  it  rheumatism,  or  heart  disease, 
or  peritonitis,  or  by  giving  it  some  other  general  term  which 
describes  the  symptoms  regardless  of  their  cause, 

A  diagnosis  of  gonorrhea  is  made,  first,  by  finding  gonococci 
in  the  pus  or  discharges  from  the  surface  of  the  body,  and  second, 
by  complement-fixation  tests  upon  the  blood. 

A  search  for  gonococci  is  a  standard  procedure  both  for  diag- 
nosis and  also  for  ascertaining  when  a  cure  is  complete.  Gon- 
orrhea is  similar  to  diphtheria  in  that  it  is  often  mild,  and  that 
its  virulent  germs  frequently  persist  without  causing  discomfort 
or  inconvenience.  An  up-to-date  physician  will  make  use  of 
laboratory  tests  in  all  cases  in  which  gonorrhea  may  be  suspected. 
The  departments  of  health  of  some  of  the  states  and  cities 
supply  the  sKdes,  mailing  cases,  and  blank  forms  for  information, 
and  make  the  examinations  free. 

A  specimen  for  making  a  laboratory  diagnosis  of  gonorrhea 
is  prepared  by  collecting  some  of  the  discharge  with  a  small 
swab  or  a  wire  loop,  smearing  it  in  a  thin  fihn  on  a  microscope 
slide,  and  letting  it  dry.  If  there  is  little  or  no  discharge  in  a 
male,  some  may  be  obtained  by  massaging  the  deep  urethra  or 


282  THE   HEALTH    OFFICER 

prostate  gland  or  by  injecting  a  weak  solution  of  nitrate  of  silver 
which  will  irritate  the  mucous  membrane  and  set  up  a  dis- 
charge. Two  samples  are  usually  taken  from  a  female,  one 
from  the  vaginal  wall  and  one  from  the  cervical  canal.  A  speci- 
men taken  within  twelve  hours  after  an  antiseptic  douche  is 
Hkely  to  be  free  from  gonococci,  but  if  no  antiseptics  have  been 
used  within  twenty-four  hours,  gonococci  may  nearly  always  be 
found  if  any  are  present  in  the  tissues. 

A  specimen  is  stained  with  the  Gram  stain,  and  examined 
with  a  iV  oil-immersion  objective.  Topical  gonococci  appear 
as  Gram-negative  diplococci  within  pus-cells.  The  location  of 
the  germs  within  a  pus-cell  is  determined  by  raising  and  lower- 
ing the  objective  while  obserN-ing  the  cell.  The  measure  of 
the  thickness  of  a  pus-cell  is  two  or  three  times  that  of  the 
depth  of  focus  of  a  rs"  oil-immersion  lens.  If  the  objective  is 
focussed  on  the  upper  surface  of  a  cell,  and  is  slowly  lowered, 
the  diplococci  ^\ithin  the  cell  first  come  into  clear  \dew  and  then 
the  lower  surface  of  the  cell  may  be  seen. 

A  complement-fixation  test  is  valuable  in  determining  the 
nature  of  the  disease  in  gonorrhea  of  the  joints  or  internal 
organs.  A  specimen  of  blood  is  taken  in  the  same  manner  as 
one  for  the  Wassermann  reaction  (page  150).  The  test  is 
usually  positive  in  gonorrheal  rheumatism  and  other  conditions 
in  which  the  micro-organisms  exist  in  the  blood;  but  it  is  nega- 
tive in  the  acute  forms  of  disease  in  which  the  germs  do  not  enter 
the  blood.  The  test  is  especially  valuable  in  determining  the 
nature  of  obscure  forms  of  inflammation  of  the  joints. 

Ophthalmia  neonatorum,  or  gonorrheal  inflammation  of  the 
eyes,  may  occur  in  newborn  children  as  a  result  of  infection  from 
mothers  who  either  have  gonorrhea  or  are  carriers  of  the  gono- 
cocci. It  also  occasionally  occurs  in  adults  by  the  transference 
of  infected  pus  to  the  eyes  by  means  of  soiled  fingers,  and  by 
towels  and  other  toilet  articles.  The  disease  is  an  intense 
inflammation  of  the  conjunctiva,  with  much  pus  and  swelling 
of  the  eyelids.  A  similar  condition  may  be  caused  by  virulent 
streptococci  derived  from  mothers  who  do  not  observe  cleanli- 
ness. A  diagnosis  is  made  by  a  microscopic  examination  of  the 
pus.  The  condition  is  dangerous  to  sight,  and  requires  skilful 
treatment.  It  may  be  prevented  in  babies  by  putting  1  drop 
of  a  1  per  cent,  solution  of  nitrate  of  silver  into  each  eye  of  a 
baby  immediately  after  its  birth. 

Gonorrhea]  infection  of  the  eyes  is  so  likely  to  occur  that  the 
New  York  State  Department  of  Health  supplies  outfits  of  nitrate 
of  silver  solution  for  gixing  the  preventive  treatment  to  every 
newborn  child.     The  department  requires  that  every  birth  cer- 


VENEREAL  DISEASES  283 

tificate  shall  contain  a  statement  of  the  means  used  for  prevent- 
ing the  development  of  the  disease;  and  if  none  are  used,  the 
reason  for  omitting  them  must  be  stated.  It  also  requires  that 
every  case  of  ophthalmia  neonatorum  shall  be  rep(;rte(l  to  the 
health  officer. 

Syphilis  is  apparently  either  a  new  disease  which  appeared 
about  the  close  of  the  fifteenth  century,  or  an  old  one  which 
suddenly  acquired  an  intense  virulency  similar  to  that  of  polio- 
myelitis in  1916.  Its  severe  nature  is  indicated  by  its  name, 
pox,  or  great  pox,  by  which  it  was  distinguished  from  the  less 
\drulent  disease,  smallpox.  Its  virulency  is  probably  as  great 
as  ever,  but  severe  acute  cases  are  now  comparatively  rare 
owing  to  the  common  use  of  the  specific  drugs — mercury,  arsenic, 
and  the  iodids — in  the  treatment  of  the  disease.  Chronic  forms 
of  the  disease,  such  as  arterial  degeneration,  locomotor  ataxia, 
and  paresis,  which  were  not  formerly  ascribed  to  syphilis,  are 
now  recognized  as  late  manifestations  of  the  disease,  especially 
in  persons  in  whom  its  early  stages  were  mild  and  unrecognized. 

Syphilis  is  caused  by  a  micro-organism,  the  Spirochaeta  pallida, 
which  may  be  classed  as  an  intermediate  form  between  the  bac- 
teria and  the  protozoa.  It  appears  Hke  the  worm  of  a  cork- 
screw having  from  three  to  twenty  well-marked  turns.  The 
spirochetes  multiply  at  their  point  of  entrance  into  the  body, 
which  is  usually  upon  a  genito-urinary  organ,  although  it  may 
be  upon  any  other  part.  The  period  of  incubation  is  about 
three  weeks.  The  first  evidence  of  the  disease  is  an  open  sore, 
called  the  primary  lesion  or  chancre,  which  appears  at  the  point 
of  infection,  and  heals  spontaneously  after  a  few  weeks. 

The  spirochetes  begin  to  enter  the  blood-stream  as  soon  as 
the  primary  sore  is  developed,  and  in  about  six  weeks  they  pro- 
duce an  eruption,  called  the  secondary  lesion,  upon  the  skin  and 
mucous  membranes.  This  period  of  the  disease  corresponds  to 
that  of  the  eruption  in  smallpox,  and  is  accompanied  by  fever, 
pain,  and  evident  sickness.  This  is  the  stage  in  which  infection 
is  usually  spread,  for  the  spirochetes  are  contained  in  the  eruptive 
spots,  and  are  given  off  when  the  spots  become  abraded  or 
ulcerated.  Patches  on  the  mucous  membranes  and  moist  sur- 
faces of  the  skin  are  particularly  infective. 

The  spirochetes  may  remain  alive  in  a  localized  part  of  the 
body  after  the  acute  symptoms  have  subsided,  and  after  years 
of  dormancy  they  may  produce  chronic  symptoms  in  almost 
any  organ,  especially  in  the  arteries,  bones,  and  nervous  system. 
The  late  manifestations  of  the  disease  are  called  tertiary  lesions. 
It  was  formerly  supposed  that  the  disease  was  not  infective 
during  this  stage,  but  the  living  spirochetes  can  often  be  found 


284  THE  HEALTH   OFFICER 

in  the  lesions  of  tertiary  syphilis,  and  may  be  given  off  if  there 
are  open  lesions  upon  the  surface. 

An  exact  diagnosis  of  sj-philis  may  be  made  by  either  of  two 
laboratory  methods,  first,  by  finding  the  characteristic  spiro- 
chetes, and  second,  by  a  complement-fixation  or  Wassermann 
test.  The  spirochetes  are  usually  present  in  the  serum  that 
exudes  from  the  primary  sore,  and  if  they  are  found,  the  diag- 
nosis is  made  with  certainty.  A  satisfactory  method  of  obtain- 
ing a  specimen  from  a  primary  sore  for  diagnosis  is  as  follows: 

1.  Wash  the  sore  with  clean,  sterile  water,  and  dry  it  with 
sterile  gauze. 

2.  Curet  the  edge  until  blood  begins  to  appear. 

3.  Wipe  the  sore  with  sterile  gauze  until  clear  serum  oozes 
from  it. 

4.  Take  a  drop  of  this  serum  upon  a  microscope  slide  for 
examination. 


Fig.  20. — Method  of  transmission  of  venereal  diseases. 

A  specimen  of  serum  must  be  examined  fresh  with  a  dark- 
field  illumination.  The  organisms  are  as  large  as  the  larger 
bacteria,  and  fresh  specimens  show  a  twisting  motion. 

The  spirochetes  may  also  be  found  among  the  tissues  beneath 
the  primary  sore.  A  small  amount  of  tissue  may  be  taken  from 
the  edge  of  the  sore,  preserved  in  a  2  per  cent,  solution  of  for- 
malin, and  sent  to  a  laboratory  to  be  sectioned,  stained,  and 
examined. 

The  complement-fixation  or  Wassermann  test  is  described  in 
the  chapter  on  Immunity  Tpage  150). 

Transmission  of  Venereal  Diseases. — The  venereal  diseases 
are  similar  in  the  methods  of  their  transmission  and  control. 
A  considerable  number  of  cases  of  venereal  diseases  are  spread 
by  ordinary  contact  with  infected  persons.     This  is  true  in  both 


VENEREAL  DISEASES  285 

gonorrhea  and  syphilis.  Epidemics  of  gonorrhea  occur  in  chil- 
dren's hospitals  and  orphanages,  and  are  difficult  to  prevent 
or  to  suppress.  Persons  affected  with  active  syphilis  frequently 
spread  the  disease  by  kissing,  towels,  and  other  direct  means  of 
transferring  the  germs.  But  transmission  of  venereal  diseases 
usually  occur  by  sexual  contact  between  persons  of  opposite 
sexes.  An  epidemic  of  the  diseases  usually  comes  from  a  very 
few  local  sources,  that  is,  from  one  or  a  few  infected  females. 
Males  are  not  the  cause  of  an  outbreak,  for  each  infected  male 
seldom  puts  himself  in  a  situation  to  spread  the  disease  exten- 
sively. An  epidemic  is  caused  by  an  infected  female,  for  she 
often  comes  in  infectious  contact  with  many  males.  There  is  a 
close  analogy  to  the  development  of  an  epidemic  of  typhoid  or 
diphtheria.  A  number  of  cases  of  venereal  disease,  or  of  typhoid 
fever,  or  of  diphtheria,  points  to  a  limited  virulent  source  of 
infection,  and  its  suppression  will  control  a  very  large  propor- 
tion of  all  cases^say  at  least  three-fourths.  The  main  part  of 
the  problem  of  preventing  venereal  diseases  is  practically  to 
discover  and  eliminate  infected  prostitutes.  The  prevention  of 
the  infection  of  prostitutes  by  discovering  and  treating  infected 
males  is  also  necessary. 

Control. — The  control  of  venereal  diseases  has  been  consid- 
ered to  be  impossible,  owing  largely  to  the  fact  that  a  large 
number  of  men  and  women  voluntarily  and  deliberately  expose 
themselves  to  infection.  The  former  attitude  of  the  public 
toward  the  diseases  was  that  of  secrecy.  Each  case  was  regarded 
as  a  private  matter,  and  the  continual  existence  of  a  grave  epi- 
demic of  preventable  disease  was  ignored.  But  from  the  time 
when  venereal  diseases  have  been  recognized  as  public  health 
problems,  great  progress  in  their  control  has  been  made.  A 
similar  development  from  secrecy  to  open  discussion  and  control 
has  taken  place  in  the  attitude  of  the  pubHc  toward  tuberculosis. 
Experience  shows  that  venereal  diseases  may  be  discussed  in  the 
same  open  manner  as  tuberculosis  or  any  other  public  health 
matter.  Effective  measures  for  preventing  venereal  diseases 
have  been  introduced  into  the  American  Army,  with  the  result 
that  they  are  rare  among  the  troops  in  many  large  camps. 
These  experiences  clearly  indicate  the  Hnes  of  work  which  prom- 
ise success  among  the  civiHan  population. 

The  measures  for  the  control  of  venereal  diseases  may  be 
divided  into  four  groups:  1,  medical;  2,  legal;  3,  educational; 
4,  social.  A  health  officer  is  directly  interested  in  the  medical 
means  of  control,  and  to  a  great  extent  also  in  the  legal  and 
educational  means.  He  is  indirectly  interested  in  the  social 
and  moral  measures  for  the  control  of  venereal  diseases. 


286  THE   HEALTH    OFFICER 

Medical  Measures. — There  are  two  essential  medical  meas- 
ures for  controlling  any  infectious  disease:  1,  the  discovery  of 
cases,  and  2.  their  treatment  to  remove  the  sources  of  infection. 
A  responsibility  rests  upon  health  officers  and  physicians  to 
make  an  accurate  diagnosis  of  cases  of  venereal  diseases,  to  give 
efficient  treatment  to  every  case,  and  to  educate  the  patients  in 
the  means  of  preventing  the  spread  of  the  diseases  to  others. 
A  laboratory  diagnosis  is  as  important  in  venereal  diseases  as  in 
diphtheria.  An  examination  of  specimens  from  every  case  is 
necessary  for  diagnosis  and  in  order  to  determine  whether  or 
not  the  disease  is  cured.  Physicians  must  be  educated  to  use 
the  laboratory,  and  the  public  must  be  educated  to  demand  its 
use. 

The  departments  of  health  of  the  larger  cities  are  establish- 
ing clinics  and  hospitals  for  the  treatment  of  venereal  diseases. 
They  have  a  great  value  in  educating  physicians  to  use  the 
modern  methods  of  treatment,  and  in  causing  patients  to  shun 
quack  doctors  and  to  seek  scientific  treatment. 

Medical  measures  for  preventing  the  development  of  a  vene- 
real disease  after  an  exposure  to  possible  infection  are  used  in 
the  American  Army  and  Naw,  but  they  have  not  come  into  gen- 
eral use  among  ci\'ilians.  The  msdom  and  propriety  of  their  use 
have  been  questioned  on  moral  grounds,  but  from  a  public  health 
point  of  \-iew  any  medical  means  of  preventing  the  diseases  are 
proper.  If  a  person  exposed  to  a  venereal  disease  seeks  pro- 
phylactic treatment,  there  is  no  valid  reason  for  deming  him 
its  benefits.  The  method  used  in  the  Army  and  Navy  is  as 
follows: 

1.  Wash  the  parts  with  soap  and  an  antiseptic  solution. 

2.  Inject  a  2  per  cent,  solution  of  protargol  into  the  urethra. 

3.  Apply  calomel  ointment  to  the  organs. 

The  procedure  is  usually  successful  when  used  soon  after 
ex-posure,  and  its  value  is  lessened  in  proportion  to  the  time  dur- 
ing which  the  germs  have  grown  in  the  body. 

Legal  Measures. — The  laws  of  customs  of  American  people 
require  patients  who  arc  afflicted  with  communicable  diseases  to 
submit  to  inconveniences  and  restrictions  in  order  to  prevent 
the  spread  of  the  diseases  to  others.  The  ideal  requirements 
in  venereal  diseases  are  that  every  patient  shall  submit  to 
efficient  treatment,  and  shall  not  expose  another  person  to 
the  danger  of  infection.  These  measures  are  observed  in  the 
Army  and  Na\'y,  and  a  beginning  has  been  made  looking 
toward  their  ultimate  adoption  among  ci\-ilians.  In  1917  and 
1918  New  York  State  adopted  four  measures  for  controlling 
patients  suffering  with  venereal  diseases.     First,  the  Council  of 


VENEREAL  DISEASES  287 

the  State  Department  of  Health  put  chancroid,  gonorrhea,  and 
syphiUis  on  the  Hst  of  diseases  which  are  subject  to  supervision 
and  control.  The  effect  is  that  a  careless  venereal  patient,  like 
a  careless  consumptive,  may  be  suh)jected  to  the  control  of  the 
health  officer  under  Section  25  of  the  Public  Health  Law,  which 
reads  as  follows:  "Every  local  board  of  health  and  every  health 
ofhcer  shall  guard  against  the  introduction  of  such  infectious  and 
contagious  or  communicable  diseases  as  are  designated  in  the 
sanitary  code,  by  the  exercise  of  proper  and  vigilant  medical 
inspection  and  control  of  all  persons  and  things  infected  with  or 
exposed  to  such  diseases,  and  provide  suitable  means  for  the 
treatment  and  care  of  sick  persons  who  cannot  otherwise  be 
provided  for."  Under  this  section  of  the  law  a  health  officer 
may  exclude  a  venereal  case  from  occupations  involving  close 
contact  with  children  and  other  persons. 

Second,  the  State  Department  of  Health  amended  the  State 
Sanitary  Code  so  that  Regulation  29a  of  Chapter  II  reads  as 
follows:  "It  will  be  the  duty  of  every  physician  when  first  at- 
tending a  person  affected  with  chancroid,  gonorrhea,  or  syphihs 
to  furnish  said  person  with  a  circular  of  information  issued  or 
approved  by  the  State  Commissioner  of  Health,  and  to  instruct 
such  person  as  to  the  precautions  to  be  taken  in  order  to  prevent 
the  communication  of  the  disease  to  others."  This  regulation 
will  stimulate  physicians  to  give  efficient  treatment  and  advice 
to  their  venereal  cases,  and  to  see  that  they  are  cured.  It  will 
doubtless  soon  lead  to  the  adoption  of  regulations  requiring  that 
venereal  diseases  shall  be  reported  to  the  health  of&cer. 

Third,  the  Legislature  of  New  York  State  amended  the 
domestic  relations  law  so  as  to  require  every  appHcant  for  a 
marriage  license  to  subscribe  to  the  following  statement:  'T 
have  not  to  my  knowledge  been  infected  with  any  venereal  dis- 
ease, or  if  I  have  been  so  infected  within  five  years,  I  have  had 
a  laboratory  test  within  that  period  which  shows  that  I  am  now 
free  from  infection  from  any  such  disease."  This  brings  the 
question  of  venereal  disease  home  to  every  young  man  and 
woman  who  expects  to  be  married.  The  observance  of  the  law 
does  not  seem  to  cause  embarrassment  or  objection  to  those 
applying  for  marriage  licenses. 

Fourth,  the  Legislature  added  subdivisions  to  Section  343  of 
the  FubHc  Health  Law,  authorizing  boards  of  health  and  health 
officers  to  examine  and  control  any  person  whom  the}'  have  good 
reason  to  suspect  to  be  likely  to  spread  a  venereal  disease.  This 
law  subjects  a  careless  person  suffering  with  a  venereal  disease 
to  the  same  kind  of  control  that  would  be  applied  to  a  person 
who  has  diphtheria  or  smallpox. 


288  THE  HEALTH   OFFICER 

Education. — The  conditions  regarding  the  control  of  venereal 
diseases  are  now  about  the  same  that  they  were  regarding  tuber- 
culosis during  the  early  days  of  the  antituberculosis  movement. 
Further  progress  will  depend  largely  on  the  education  of  phy- 
sicians, patients,  and  the  public,  as  in  the  control  of  tuberculosis. 

Every  health  officer  is  expected  to  become  familiar  with  mod- 
ern methods  of  diagnosis  and  treatment  of  venereal  diseases, 
and  to  recommend  them  to  the  physicians  in  his  jurisdiction. 
He  is  expected  to  have  supplies  of  diagnostic  outfits  and  educa- 
tional literature  if  they  are  furnished  by  his  state  department  of 
health  or  other  agency. 

When  patients  afflicted  with  \enereal  diseases  receive  the 
benefits  of  scientific  treatment  and  the  advice  required  by  the 
sanitary  code  of  the  New  York  State  Department  of  Health, 
they  become  centers  for  spreading  the  knowledge  to  others  and 
of  influencing  others  to  seek  adequate  treatment.  The  educa- 
tion of  patients  is  a  valuable  means  of  reaching  the  pubhc. 

The  education  of  the  pubUc  regarding  venereal  diseases  is 
conducted  along  two  lines,  first,  concerning  the  diseases  them- 
selves, and  second,  regarding  sex  matters  in  general.  It  is  the 
work  primarily  of  social  workers  and  teachers,  but  a  health 
officer  can  be  of  great  assistance  to  them. 

The  very  great  value  of  moral  teaching  must  also  be  recog- 
nized. An  appeal  to  the  moral  nature  is  one  of  the  most  com- 
pelling forces  for  controlHng  the  passions  and  animal  incUna- 
tions  of  men  and  women. 

Social  Measures. — Social  and  community  measures  are  also 
necessary  for  controlling  venereal  diseases.  One  measure  is 
pro\'ision  for  proper  amusement  and  recreation  for  young  peo- 
ple. If  thoughts  of  animal  passions  and  feelings  are  to  be  con- 
trolled, they  must  be  displaced  by  higher  thoughts  and  feelings. 

The  prevention  of  venereal  diseases  is  closely  connected  with 
the  problem  of  alcohohc  liquors.  Temperance  measures  are 
among  the  most  necessary  and  efficient  means  of  suppressing 
venereal  diseases,  and  of  dealing  with  many  problems  concerning 
sexual  relations. 

Measures  for  the  control  and  suppression  of  prostitution  are 
also  necessary.  Experience  has  shown  that  the  regulation  of 
prostitution  is  a  failure  in  preventing  venereal  diseases.  Prosti- 
tution is  the  greatest  factor  in  spreading  venereal  diseases,  and 
the  moral  sense  of  the  American  people  will  not  allow  its  legal- 
ization and  supervision.  Its  suppression  is  a  necessary  public 
health  measure. 

Summary. — The  various  protective  measures  against  attacks 
of  venereal  diseases  may  be  represented  by  circles  of  outposts 


VENEREAL  DISEASES  289 

surrounding  each  individual.     These  circles  from  without  in- 
ward are: 

1.  Social  and  moral  forces,  and  the  standards  of  civilized 
society. 

2.  Education  regarding  sex  matters  and  sex  diseases. 

3.  Wholesome  recreation  and  mental  occupations. 

4.  Legal  control  of  prostitutes. 

5.  The  treatment  and  cure  of  cases. 

6.  Prophylactic  treatment  for  those  who,  in  spite  of  other 
measures,  persist  in  exposing  themselves  to  infection. 

19 


CHAPTER  XXVII 

TUBERCULOSIS 

The  Problem. — Tuberculosis  constitutes  one  of  the  biggest 
and  most  neglected  of  all  the  problems  with  which  a  health 
officer  has  to  deal.  Although  tuberculosis  was  one  of  the  first 
diseases  in  which  the  specific  germs  were  discovered,  bacteri- 
ologists have  not  been  able  to  develop  direct  methods  of  its 


Fig.  21. — Method  of  transmission  of  tuberculosis. 

treatment  or  prevention  similar  to  those  used  in  diphtheria  and 
smallpox.  The  management  of  the  tuberculosis  problem  is  a 
severe  test  of  a  health  officer's  activity,  judgment,  and  influence, 
for  the  treatment  and  prevention  of  the  disease  involves  doing 
a  long  series  of  commonplace  acts  by  the  patient,  his  family, 
his  physician,  and  often  by  social  organizations.  We  now  pos- 
290 


TUBERCULOSIS  291 

sess  sufficient  knowledge  of  the  disease  to  control  it  if  the  health 
ofificer  in  each  community  will  be  a  leader,  and  will  organize  the 
forces  for  its  treatment  and  suppression. 

The  Bacteria. — Tuberculosis  is  caused  by  a  small  rod-shaped 
bacillus  which  may  grow  in  almost  any  part  of  the  body,  but 
the  health  officer  is  especially  interested  in  pulmonary  tuber- 
culosis or  consumption,  which  is  produced  by  the  growth  of  the 
bacilli  in  the  lungs.  The  bacilli  may  be  readily  grown  in  cul- 
tures, but  they  make  an  extremely  slow  growth,  and  in  a  month 
their  development  is  usually  no  greater  than  that  of  diphtheria 
germs  in  a  day.  The  slow  development  accounts  in  part  for 
the  insidiousness  of  the  disease,  and  for  the  many  and  varied 
forms  which  the  disease  often  assumes. 

Tuberculosis  germs  do  not  multiply  under  ordinary  condi- 
tions after  they  have  been  expelled  from  the  body.  Sunlight  is 
especially  harmful  to  them.  They  may  survive  drying  for  some 
days,  and  may  be  found  in  the  dust  of  extremely  dirty,  dark 
rooms;  and  they  may  also  be  found  in  the  dust  of  streets  into 
which  they  have  been  expelled  by  careless  spitters.  They  will 
survive  for  days  in  dark,  damp  places  when  they  are  protected 
from  the  sunlight  by  coverings  of  dirt,  and  they  are  frequently 
found  in  house  dust  which  has  recently  been  raised  from  dirt 
and  filth  containing  the  germs. 

The  large  number  of  tuberculosis  cases  in  every  community 
makes  it  probable  that  tuberculosis  germs  are  widely  distributed, 
and  that  some  have  entered  the  body  of  every  person  through 
the  nose  with  dust,  or  through  the  mouth  with  food.  Whether 
or  not  the  germs  produce  the  disease  will  depend  principally 
on  the  degree  of  immunity  of  the  person.  The  lungs  of  over  half 
of  all  people  show  slight  evidences  of  the  growth  of  tuberculosis 
germs  in  them,  but  it  may  be  that  these  germs  act  like  a  vaccine 
and  protect  the  person  against  further  infection.  The  prevalence 
of  the  scars  left  by  healed  tuberculosis  has  given  rise  to  the  state- 
ment that  everybody  has  tuberculosis,  but  this  is  not  true  if  by 
tuberculosis  we  mean  a  disease  in  which  there  is  evident  sick- 
ness. But  these  old  scars  are  of  great  importance,  for  a  few 
tubercle  germs  may  remain  alive  in  them  for  years,  and  when 
the  body  becomes  weakened  from  any  cause,  they  may  mul- 
tiply and  produce  extensive  disease. 

When  the  germs  of  tuberculosis  enter  the  body  either  through 
the  nose  or  by  way  of  the  stomach,  they  usually  find  their  way 
to  the  lungs,  and  there  give  rise  to  white  bodies  about  the  size 
of  pin  heads,  called  tubercles,  in  which  the  tuberculosis  germs 
are  found.  The  germs  and  their  poisons  also  cause  the  neigh- 
boring lymph-glands  to  become  enlarged.     The  tubercles  and 


292  THE   HEALTH    OFFICER 

the  enlarged  glands  are  the  first  gross  effects  that  are  produced 
by  the  germs. 

Other  germs,  such  as  streptococci,  may  also  enter  the  body 
and  grow  along  with  the  tubercle  germs.  Many  of  the  effects 
of  severe  cases  of  tuberculosis  are  due  to  the  other  germs  which 
are  associated  with  the  tubercle  bacilli. 

Examination  for  Tubercle  Bacilli. — The  recognition  of  pul- 
monary tuberculosis  is  made  with  certainty  by  finding  tubercle 
bacilli  in  the  sputum.  Their  slowness  of  growth  makes  it  im- 
practicable to  use  cultures,  and  so  the  sputum  is  examined  di- 
rectly. The  tubercle  germs  in  it  are  recognized  by  their  pecu- 
liarities of  staining.  They  belong  to  the  acid-fast  group,  mean- 
ing that  they  retain  their  stain  when  they  are  acted  on  by  acids 
which  will  remove  the  stains  of  most  other  kinds  of  bacteria. 
About  3  per  cent,  of  the  substance  of  tubercle  bacilli  consists 
of  wax  which  hinders  the  entrance  of  the  stains  into  the  bacilli, 
and  after^vard  protects  the  stains  in  the  bacilli  from  decolorizing 
agents.  The  wax  also  tends  to  prevent  the  bacilli  from  drying, 
and  thus  it  prolongs  their  life  outside  the  body. 

The  method  of  preparing  a  sample  of  sputum  for  examination 
is  as  follows: 

1.  Spread  a  small  bit  of  thick  sputum  upon  a  microscope 
slide  and  fix  it  by  heat. 

2.  Apply  carbolfuchsin  as  a  stain  for  about  five  minutes. 

3.  Wash  off  the  stain  and  apply  a  3  per  cent,  solution  of 
hydrochloric  acid  in  alcohol  in  order  to  remove  the  carbolfuchsin 
from  all  the  germs  except  the  tubercle  germs. 

4.  Stain  the  specimen  with  methylene-blue,  which  will  color 
all  the  parts  of  the  specimen  except  the  tubercle  germs,  which 
remain  red. 

The  recognition  of  tubercle  germs  would  be  easy  if  their 
numbers  could  be  multiplied  readily  by  cultures,  but  only  a  few 
are  usually  found  in  a  specimen  of  sputum,  and  it  may  be  neces- 
sary to  examine  many  fields  under  the  microscope  before  a  single 
bacillus  is  found,  and  to  spend  an  hour  in  the  examination  of  a 
single  specimen  in  order  to  make  sure  that  it  contains  no  tubercle 
germs. 

There  are  several  methods  of  concentrating  the  germs  in  a 
specimen  in  order  to  increase  the  probabilities  of  finding  them 
there.     One  is  as  follows : 

1.  Mix  the  sputum  with  antiformin,  and  let  it  stand  for  fif- 
teen minutes  in  an  incubator  in  order  to  liquefy  the  sputum. 

2.  Centrifuge  the  mixture  and  examine  the  sediment  for  the 
bacilli. 

Many  state  departments  of  health  supply  health  officers  with 


TUBERCULOSIS  293 

outfits  for  collecting  and  mailing  specimens  of  sputum  for  ex- 
amination. The  specimen  must  actually  come  from  the  bronchi 
in  order  to  be  of  use,  and  not  be  merely  a  collection  of  saliva 
and  nasal  mucus.  If  a  health  officer  receives  a  report  that  no 
tubercle  bacilli  were  found,  he  is  not  to  conclude  that  the  person 
does  not  have  tuberculosis.  The  health  ofiicer  may  not  have 
sent  a  specimen  from  the  lungs,  or  the  patient  may  not  have 
been  giving  off  bacilli  at  the  time  of  the  examination.  Still,  the 
examination  of  sputum  is  the  most  reliable  and  ready  means  of 
diagnosis  which  a  health  officer  has. 

Errors  in  diagnosis  are  sometimes  made  by  mistaking  other 
acid-fast  bacteria  for  the  tubercle  bacilli.  An  acid-fast  bacillus 
similar  to  tubercle  bacilli  grows  on  hay,  and  is  found  in  the 
intestines  of  cows  and  often  in  milk.  Another  acid-fast  bacillus 
is  often  found  contaminating  specimens  of  urine,  and  leads  to 
erroneous  deductions  regarding  tuberculosis  of  the  kidneys. 
These  acid-fast  bacilli  do  not  grow  readily  in  inoculated  animals, 
and  they  may  be  excluded  by  animal  inoculation  tests. 

Animal  Inoculation  Test. — If  a  specimen  contains  so  few 
germs  that  they  cannot  be  found  in  a  stained  specimen,  or  if 
there  is  a  possibility  of  the  contamination  of  a  specimen  by 
other  acid-fast  bacilli,  the  tubercle  germs  may  be  identified  by 
their  growth  after  inoculation  into  young  guinea-pigs.  These 
animals  are  extremely  susceptible  to  tubercle  bacilh.  An  in- 
oculation of  the  suspected  material  is  made  into  the  thigh  sub- 
cutaneously  or  intramuscularly.  If  the  tubercle  bacilli  are  pres- 
ent, the  first  effect  will  be  the  enlargment  of  the  lymph-glands 
of  the  groin  in  about  three  weeks,  and  is  usually  followed  by 
the  death  of  the  animal  in  four  or  five  weeks.  When  the 
animal  is  examined,  a  pure  culture  of  the  tubercle  bacilli  will 
be  found  in  the  glands,  and  the  characteristic  lesions  of  tuber- 
culosis will  be  found  in  the  abdominal  organs.  The  animal 
inoculation  test  is  delicate  and  certain,  but  it  requires  three  or 
four  weeks  to  make. 

Susceptibility  and  Immunity. — Nearly  every  person  is  sus- 
ceptible to  tuberculosis  germs,  but  there  must  be  some  form  of 
immunity  to  account  for  recovery  from  the  disease.  The  injec- 
tion of  tuberculosis  germs  produces  agglutinins  and  lysins  in  the 
body,  but  in  such  an  irregular  manner  that  they  cannot  be 
utilized  for  diagnosis  or  treatment.  The  immunity  to  tuber- 
culosis does  not  seem  to  depend  upon  the  production  of  an  anti- 
toxin or  other  antibody,  but  upon  the  resistance  of  the  indi\ddual 
cells  of  the  body.  If  the  body  is  weakened  by  any  cause,  such 
as  overwork  or  alcohol,  the  resistance  of  all  the  cells  of  the  body 
is  lowered  to  such  a  degree  that  tuberculosis  germs  may  readily 


294  THE    HEALTH    OFFICER 

grow  and  produce  disease.  Innumerable  attempts  have  been 
made  to  produce  artificial  immunity  by  the  injection  of  tuber- 
culosis germs  or  their  poisons.  The  results  of  these  experiments 
seem  to  indicate  that,  while  a  person  has  a  few  germs  actively 
growing  in  his  body,  he  is  protected  against  the  growth  of  more 
germs  which  may  enter  it.  But,  on  the  other  hand,  if  a  person 
has  the  germs  already  growing  in  the  bod}-,  anything  which 
lowers  the  general  health  of  the  bod}'  tends  to  allow  these  germs 
to  grow  and  spread,  and  produce  the  disease  in  a  severe  form. 

Immunity  to  tuberculosis  depends  mainly  on  \igorous  health. 
If  a  person  is  sick  with  tuberculosis,  his  recovery  depends  prin- 
cipally on  doing  those  ordinary,  every-day  things  which  tend  to 
make  a  well  person  strong  and  vigorous.  There  is  no  antitoxin, 
or  seruni,  or  drug  which  has  an  appreciable  effect  in  producing 
immunity  to  tuberculosis. 

Tuberculin. — Tubercular  diseases  may  often  be  recognized  by 
what  is  called  the  tuberculin  reaction.  Tuberculin  is  the  liquid 
in  which  tuberculosis  germs  have  grown.  Another  form  of  tuber- 
culin is  the  dried  genns  dissolved  in  water.  Neither  contains 
\\\\ng  germs.  When  tuberculin  is  injected  into  a  normal  person, 
it  produces  no  effect,  but  a  very  small  amount  causes  fever  in  a 
person  who  has  tuberculosis.  This  test  is  used  in  various  forms, 
but  the  most  common  is  that  of  von  Pirquet.  The  test  is  per- 
formed as  follows:  Scratch  the  superficial  layers  of  epidennis 
from  two  areas  of  skin  upon  the  forearm,  each  about  the  size  of 
an  "o"  of  ordinary  newspaper  print.  Apply  a  drop  of  tuberculin 
to  one  area  and  leave  the  other  untouched  for  comparison.  If 
a  person  has  tuberculosis,  a  red  area  about  the  size  of  a  dime 
will  develop  around  the  spot  touched  with  tuberculin,  while 
the  other  spot  will  remain  normal.  The  von  Pirquet  test  is 
valuable  for  detecting  tuberculosis  in  babies,  but  the  test  is  so 
sensitive  that  it  produces  red  areas  on  the  skins  of  many  grown 
persons  who  have  no  evident  signs  of  tuberculosis,  although  it 
is  probable  that  they  have  the  scars  of  small  tubercular  lesions 
which  have  healed.  A  practical  application  of  tuberculin  tests 
is  made  in  the  detection  of  tuberculosis  in  cattle  (page  353). 

Many  experiments  have  been  made  in  treating  tuberculosis 
with  injections  of  tuberculin  with  the  intention  of  producing 
immunity  to  the  disease.  But  the  process  is  difficult  and 
dangerous  and  has  not  been  satisfactorily  developed.  The  body 
seems  to  respond  only  to  the  degree  of  producing  conditions 
resembling  an  anaphylaxis  which  does  not  go  on  to  the  produc- 
tion of  sufficient  antibodies  to  have  a  beneficial  effect. 

Types  of  Tubercle  Germs. — Four  main  t}pcs  of  tuberculosis 
are  well   recognized:    1,   human,   affecting  persons;   2,   bovine, 


TUBERCULOSIS  295 

affecting  horned  cattle;  3,  avian,  affecting  birds;  4,  a  group  af- 
fecting cold-blooded  animals.  Human  beings  are  susceptible 
to  the  bovine  type  of  tuberculosis.  Although  this  was  long  dis- 
puted, the  explanation  is  that  grown  persons  are  almost  entirely 
immune  to  the  bovine  type,  but  children  are  somewhat  suscep- 
tible. About  10  per  cent,  of  all  child  deaths  from  consumption 
are  caused  by  the  bovine  type  of  tubercle  bacilli.  The  chief 
situations  in  which  the  bovine  type  of  tubercle  bacilli  occur  are 
the  glands  of  the  neck  and  of  the  abdomen.  These  situations 
are  what  one  would  expect  from  the  fact  that  the  bovine  type  is 
usually  caught  by  drinking  milk  from  tubercular  animals. 

A  diagnosis  may  be  made  between  the  human  and  the  bovine 
type  of  tubercle  bacilli  by  injecting  the  suspected  bacilli  into  a 
rabbit.  This  animal  is  extremely  susceptible  to  bovine  tuber- 
culosis, and  much  less  so  to  the  human  type.  If  the  germs  that 
are  injected  are  of  the  bovine  type,  the  rabbit  will  have  tuber- 
culosis of  practically  all  the  internal  organs,  while  if  it  is  of  the 
human  type,  only  the  lungs  or  the  liver  or  both  will  be  affected. 

Prevalence  of  Tuberculosis. — Health  officers  frequently  give 
the  excuse  for  doing  little  tuberculosis  work  that  there  are  very 
few  cases  in  their  jurisdiction.  Tuberculosis  is  epidemic  every- 
where. About  one-tenth  of  all  deaths  are  due  to  it,  and  the 
number  of  living  cases  in  a  community  is  about  five  times  the 
number  of  annual  deaths  from  tuberculosis.  Every  health 
officer  has  cases  within  his  jurisdiction,  and  it  is  his  duty  to  search 
them  out  and  to  make  an  earnest  attempt  to  suppress  the  epi- 
demic. A  health  officer  has  three  duties  to  perform:  first,  to 
record  the  cases  as  in  epidemics  of  other  communicable  diseases; 
second,  to  protect  the  public  from  further  spread  of  the  disease; 
and  third,  to  see  that  the  cases  receive  the  proper  treatment. 

Records. — The  laws  of  the  state  of  New  York  require  phy- 
sicians to  report  all  their  cases  of  tuberculosis  to  the  local 
health  officers,  but  the  health  officers  often  get  few  reports, 
especially  in  the  rural  communities.  Most  of  the  cases  employ 
no  physician  regularly,  but  go  from  doctor  to  doctor.  Many 
doctors  do  not  recognize  the  disease  until  the  victims  are 
dying.  The  present  condition  in  regard  to  reporting  tubercu- 
losis is  like  that  of  diagnosing  diphtheria  in  only  those  cases 
which  show  marked  signs  of  croup.  Reporting  tuberculosis  is  a 
new  procedure,  and  the  law  has  required  that  the  reports  be 
kept  secret.  But  this  feeling  of  secrecy  is  passing  awa}^  with 
the  demonstration  that  reporting  cases  leads  to  helping  the  vic- 
tims and  often  to  restoring  them  to  health. 

There  has  been  a  strong  public  fear  of  tuberculosis  cases,  and 
the  victims  often  conceal  their  illness  for  fear  that  thev  will 


296  THE  HEALTH   OFFICER 

lose  their  positions  or  their  social  standing,  or  that  tuberculosis 
always  means  sure  death.  But  there  is  a  stage  when  tuber- 
culosis is  not  a  loathsome  disease,  when  it  can  scarcely  be  recog- 
nized by  an  ordinary  person,  when  there  is  Uttle  danger  of 
giving  it  to  another  person,  and  when  it  can  be  readily  cured. 
The  problem  before  the  health  officer  is  to  get  the  cases  in  this 
early  stage,  and  to  prevent  the  disease  from  going  on  to  advanced 
forms.  This  work  is  a  test  of  the  efficiency  of  a  health  officer. 
If  he  is  active  and  has  public  health  work  at  heart,  he  will  seek 
to  get  physicians  to  report  cases,  and  will  also  go  out  and  seek 
the  cases  himself.  He  will  follow  up  rumors  and  reports  from 
schools,  social  organizations,  charitable  societies,  and  churches, 
and  will  endeavor  to  co-ordinate  the  forces  for  the  control  of  the 
disease. 

Recognition  of  Cases. — One  great  difficulty  with  which  a 
health  officer  has  to  deal  is  a  failure  of  the  public  and  physicians 
to  recognize  cases  of  tuberculosis  in  the  curable  stage.  The 
health  officer  will  recognize  the  cases  by  three  methods:  first, 
by  a  history  of  the  cases;  second,  by  a  sputum  examination;  and 
third,  by  a  physical  examination  of  the  lungs. 

Most  cases  of  tuberculosis  begin  like  a  prolonged  cold,  and 
the  victims  feel  tired  all  the  time,  as  if  they  were  overworked. 
If  there  are  signs  of  a  persistant  cold  with  some  cough  and  loss 
of  weight  and  strength,  there  are  good  grounds  for  at  least 
suspecting  tuberculosis,  and  for  seeking  examinations  of  the 
sputum  and  chest  to  determine  the  presence  or  absence  of  the 
disease. 

The  presence  of  tuberculosis  is  positively  determined  by 
finding  tubercle  germs  in  the  sputum.  The  departments  of 
health  of  some  of  the  states  and  of  the  larger  cities  examine 
specimens  free  of  cost,  and  supply  health  officers  \\'ith  containers 
for  sending  specimens  to  a  laboratory.  It  is  the  duty  of  the 
health  officer  and  the  physicians  to  make  use  of  the  facilities  for 
sputum  examination.  Finding  tubercle  germs  fixes  the  diag- 
nosis of  tuberculosis,  but  failure  to  find  them  does  not  exclude 
the  disease  (page  293). 

Physical  Examination. — An  expert  health  officer  or  physician 
should  be  able  to  recognize  tuberculosis  by  the  physical  signs 
of  the  lungs  before  tubercle  bacilli  appear  in  the  sputum.  The 
two  physical  signs  which  almost  positively  indicate  tuberculosis 
are  an  afternoon  fever  without  an  apparent  cause  and  the 
presence  of  slight  lung  signs,  especially  a  few  rales,  in  any  part 
of  the  lungs.  These  rales  will  be  heard  at  the  base  almost  as 
frequently  as  at  the  apex.  A  valuable  sign  which  is  almost 
constantly  found  is  a  few  rales  heard  at  the  beginning  of  an 


TUBERCULOSIS  297 

inspiration  which  is  taken  after  a  person  has  coughed  at  the  end 
of  expiration.  Many  physicians  are  not  familiar  with  these 
slight  signs  of  the  disease.  It  is  the  duty  of  the  health  officer  to 
study  to  make  himself  an  expert  in  these  physical  signs,  to  teach 
them  to  the  physicians  within  his  jurisdiction,  and  to  get  their 
co-operation  in  the  examination  of  the  cases.  This  requires 
tact  and  enthusiasm  on  the  part  of  the  health  ofhcer;  but  he 
cannot  do  effective  tuberculosis  work  unless  he  is  deeply  inter- 
ested in  the  subject  and  is  willing  to  study  and  work. 

An  x-ray  examination  of  the  lungs  will  reveal  spots  of  con- 
solidation and  is  a  valuable  means  of  detecting  the  disease  in 
small  areas  both  in  the  beginning  of  the  disease  and  after  they 
have  healed. 

Experience  in  the  army  has  demonstrated  that  when  men 
live  under  crowded  conditions,  a  low  grade,  chronic  infection 
with  streptococci  frequently  occurs  in  the  lung,  and  produces 
an  area  of  inflammation  which  gives  the  symptoms  and  physical 
signs  of  tuberculosis.  These  cases  have  no  tubercle  bacilli  in 
their  sputum.  They  nearly  always  recover  under  treatment 
with  fresh  air,  good  food,  and  rest. 

Protection  of  the  Public. — Tuberculosis  does  not  come  from 
a  cold,  or  overwork,  or  exposure,  but  it  is  a  communicable  disease, 
and  is  caught  from  some  person  or  animal  that  has  it.  A  per- 
son who  has  the  disease  gives  off  the  germs  with  the  sputum," 
and  the  prevention  of  the  spread  of  the  disease  consists  of  taking 
care  of  the  sputum  of  the  cases.  The  patient  is  to  expectorate 
into  a  cup  or  a  napkin,  and  the  sputum  is  to  be  burned  or  buried. 
The  patient  is  to  avoid  spitting  on  floors  of  public  places  or  in 
any  place  from  which  the  germs  may  escape.  He  is  to  avoid 
kissing  other  persons  or  doing  anything  by  which  his  sputum 
may  be  spread.  His  dishes,  knives  and  forks,  towels,  and  other 
eating  utensils  are  to  be  cleansed  in  hot  water.  If  a  patient  does 
these  things,  he  will  not  be  likely  to  give  the  disease  to  other 
persons. 

Tuberculosis  patients  may  be  divided  into  two  classes:  those 
who  have  tubercle  bacilli  in  their  sputum  and  those  who  do  not 
have  it.  Tubercle  bacilli  do  not  appear  in  the  sputum  until 
the  tissues  of  the  lungs  begin  to  break  down.  The  incipient 
cases  are  not  likely  to  have  tubercle  bacilli  in  their  sputum, 
and  may  go  in  public  places  without  danger  to  other  persons. 
The  degree  of  danger  in  each  case  of  tuberculosis  must  be  judged 
by  itself.  The  elements  to  be  considered  in  judging  the  danger 
from  a  case  of  tuberculosis  are:  first,  the  number  of  germs  in 
the  sputum;  second,  the  reliability  and  intelligence  of  the  pa- 
tient in  regard  to  caring  for  his  sputum;  and  third,  his  ability, 


298  THE   HEALTH    OFFICER 

physically  and  financially,  to  carry  out  the  instructions  of  the 
physicians  and  health  officer.  An  intelligent  patient  in  mod- 
erate circumstances  who  is  conscientious  can  readily  take  care 
of  himself  and  his  sputum  in  such  a  way  that  he  may  mingle 
with  other  persons  without  danger  of  spreading  the  disease.  On 
the  other  hand,  a  patient  is  a  menace  to  the  public  if  he  is  un- 
reliable or  stupid,  or  is  so  weakened  by  the  disease  that  he  is 
unable  to  procure  the  necessities  of  life. 

The  protective  measures  which  a  health  officer  may  adopt 
are:  first,  to  provide  sputum  cups,  paper  napkins,  and  other 
utensils  which  a  patient  needs  in  caring  for  his  sputum;  second, 
to  see  that  a  patient  receives  proper  treatment;  third,  to  secure 
his  removal  to  a  hospital  if  one  is  available;  and  fourth,  to  in- 
struct the  patient  and  his  family,  and  to  maintain  an  oversight 
over  him.  The  health  officer  or  his  helpers  will  need  to  make 
many  \'isits  to  a  patient.  Perfunctory  oversight  will  accompKsh 
nothing,  and  no  measures  will  do  much  good  unless  the  health 
officer  succeeds  in  obtaining  the  co-operation  of  the  patients  and 
their  families. 

Treatment. — It  is  the  duty  of  a  health  officer  to  secure 
treatment  for  cases  of  tuberculosis  not  only  for  the  benefit  of 
the  patients  themselves,  but  for  the  protection  of  the  members 
of  their  families  and  of  the  public.  The  old  idea  of  treatment  of 
tuberculosis  was  that  a  change  of  climate  was  necessary.  Cases 
from  mountainous  regions  w^ere  sent  to  the  sea-shore  and  those 
from  the  sea-shore  were  sent  to  the  mountains.  We  now-  know 
that  climate  and  change  of  air  are  minor  considerations  in  pro- 
ducing the  cure.  A  patient  can  get  well  in  his  own  home  town 
as  quickly  and  completely  as  he  can  in  a  distant  land. 

An  experimental  method  of  treatment  is  the  use  of  vaccines 
with  the  expectation  of  producing  an  immunity  to  the  disease. 
The  sickness  and  fever  in  many  cases  of  tuberculosis  are  due  not 
so  much  to  the  tubercle  germs  as  to  streptococci  and  other 
germs  which  are  associated  with  the  tubercle  germs.  Vaccines 
sometimes  have  efTects  in  destroying  the  associated  germs,  and 
the  body  thus  relieved  of  its  burden  may  be  better  able  to  over- 
come the  tubercle  germs.  Vaccines  for  the  destruction  of  tu- 
bercle germs  themselves  have  not  produced  cures  (page  293). 

All  manner  of  drugs  and  special  foods  and  applications  have 
been  tried,  and  all  have  been  found  wanting. 

The  three  essential  things  in  the  cure  of  tuberculosis  are 
fresh  air,  nourishing  food,  and  rest.  These  are  extremely  simple 
things,  and  because  they  are  so  simple  they  are  often  difficult  to 
obtain.  It  does  no  good  for  a  health  officer  to  prescribe  fresh 
air  when  a  large  family  is  housed  in  crowded  quarters  without 


TUBERCULOSIS  299 

heat  and  with  insufficient  clothing,  or  when  the  family  does  not 
possess  the  means  for  buying  food,  or  when  the  sick  person  must 
work  to  maintain  himself  and  his  family.  The  rich  man  who  has 
a  cough  and  is  overworked  gets  relief  by  taking  a  vacation;  but 
a  poor  person  must  stay  at  home  and  make  use  of  the  meager 
facihties  which  he  has.  It  is  the  duty  of  the  health  officer  to 
see  that  the  means  of  treatment  are  provided.  This  is  largely 
a  social  problem,  and  requires  the  co-operation  of  the  churches 
for  the  comfort  and  solace  which  they  afford;  of  charitable 
societies  for  their  supplies  of  food  and  clothing;  and  of  reform 
leagues  for  laws  to  compel  municipalities  to  provide  the  means 
for  the  care  of  the  cases.  If  a  health  officer  is  unable  to  obtain 
all  the  things  which  are  necessary  for  the  treatment  of  a  tuber- 
culosis case  at  once,  he  can  at  least  agitate  the  subject  and  talk 
about  it  persistently  until  he  rouses  the  public  and  ofhcials  to 
provide  the  means  for  treatment. 

The  health  officer  will  naturally  divide  cases  of  tuberculosis 
into  three  classes:  first,  the  incipient  class,  or  those  in  which  no 
germs  are  found  in  the  sputum,  and  which  have  only  mild, 
beginning  symptoms.  These  cases  will  get  well,  and  may  be 
safely  treated  at  their  home,  and  may  continue  at  work. 

The  second  class  of  cases  are  those  who  are  giving  off  germs 
with  their  sputum,  but  who  will  get  well  if  they  take  great  care 
of  themselves.  Some  of  these  cases  may  be  safely  treated  at 
home,  but  others  will  require  considerable  assistance  and  pos- 
sibly expert  care  in  a  hospital. 

The  third  class  of  cases  are  those  who  are  advanced  so  far 
that  they  cannot  get  well.  If  they  are  poor  and  remain  at 
home,  they  often  give  the  disease  to  other  members  of  the  family. 
These  cases  require  treatment  in  hospitals  not  merely  for  their 
own  comfort,  but  for  the  protection  of  their  own  famihes  and  the 
public.  Every  advanced  case  passes  through  the  stages  of 
incipiency  and  moderate  advancement,  and  it  is  the  duty  of 
the  health  officer  to  offer  the  means  for  the  detection  and  care 
of  these  cases  in  the  early  stages  of  the  disease. 

The  health  officer  cannot  attend  to  all  the  cases  alone.  He 
must  have  the  co-operation  of  many  assistants,  and  his  success 
will  depend  upon  his  ability  to  secure  their  services. 

An  assistant  which  is  almost  absolutely  necessary  for  a 
health  officer  to  carry  out  tuberculosis  work  is  a  pubhc  health 
nurse.  Her  duty  is  to  visit  the  homes  of  the  patients  and  to 
instruct  them  in  their  breathing,  eating,  and  rest,  and  to  do 
simple  nursing  for  them  if  it  is  necessary.  She  ^^'ill  also  keep 
track  of  their  needs,  and  will  see  that  the  proper  officers  supply 
them. 


300  THE   HEALTH    OFFICER 

A  tuberculosis  sanatorium  is  also  almost  indispensable  in 
combating  tuberculosis.  A  hospital  is  not  merely  a  place  where 
patients  receive  treatment.  Its  chief  value  is  that  it  is  a  school 
of  instruction  where  the  curable  cases  can  go  and  learn  to  breathe, 
eat,  and  rest.  It  is  also  an  isolation  place  where  advanced  cases 
can  receive  care  and  where  they  will  not  be  a  menace  to  the 
community. 

A  great  problem  in  tuberculosis  work  is  how  the  health  officer 
is  to  enable  recovered  persons  to  live  as  they  should  after  they 
leave  the  hospital.  If  they  have  to  work  hard  for  their  living, 
or  to  provide  for  the  necessities  for  a  large  family,  they  will 
soon  relapse  and  be  sick  wdth  the  disease  again.  It  is  the  duty 
of  public  ofhcials  to  pro^^de  the  means  by  which  these  persons 
may  be  relieved  of  the  greater  burdens  of  life. 


CHAPTER  XXVIII 

INSECT-BORNE  DISEASES 

MALARIA 

Malaria  is  a  communicable  disease  whose  control  and 
prevention  is  a  public  health  problem.  It  is  caused  by  a  pro- 
tozoon,  formerly  called  the  Plasmodium  malarise,  but  now  the 
Haemamoeba  malariae.  The  organisms  grow  in  the  blood  and 
destroy  the  red  blood-cells.  They  multiply  in  human  blood  by 
segmenting  or  dividing  every  forty-eight  or  seventy-two  hours, 
according  to  the  type  of  the  disease.  A  chill  and  fever  follow 
each  segmentation. 


^ 

J 

■^=-^% 

# 

»• 

nO>QUITO             ^ 

7i 

HUnfHN 

cAse 

KATES 

Fig.  22. — Method  of  transmission  of  malaria  and  yellow  fever. 

The  parasites  of  malaria  may  be  transferred  from  a  malarial 
patient  to  another  person  by  the  transfusion  of  blood,  but  the 
ordinary  method  of  their  transference  is  by  means  of  blood- 
sucking mosquitoes.  When  the  organisms  are  taken  into  a 
mosquito,  they  undergo  a  sexual  development  and  multiplica- 
tion. They  are  then  found  in  the  salivary  glands  of  the  mos- 
quito, and  are  injected  into  the  persons  whom  the  insect  bites. 
The  affected  mosquito  itself  does  not  seem  to  be  harmed  by  the 
malarial  parasite,  but  it  may  live  for  weeks,  and  may  bite  and 
infect  many  persons.  The  organisms  appear  in  the  salivary  glands 
in  from  seven  to  ten  days  after  a  mosquito  has  bitten  a  malarial 
patient.  When  a  well  person  is  inoculated  by  an  infected  mos- 
quito, he  will  have  his  first  chill  in  from  one  to  three  weeks.  It 
therefore  takes  from  two  to  four  weeks  for  a  secondary  case  of 
malaria  to  develop  from  a  primary  case. 

301 


302  THE    HEALTH    OFFICER 

The  Mosquito. — The  only  mosquitoes  that  carry  malaria 
germs  are  those  belonging  to  the  genus  Anopheles.  The  two 
common  species  that  produce  malaria  in  the  United  States  are 
the  Anopheles  quadrimaculatus  and  the  Anopheles  punctipennis. 
A  ready  means  of  recognizing  an  anopheles  mosquito  is  that  it 
rests  with  its  body  at  nearly  right  angles  to  the  surface  on  which 
it  alights,  while  other  mosquitoes  rest  with  their  bodies  parallel 
to  the  surface.  The  anopheles  mosquito  is  a  night  flier,  and  this 
peculiarity  accounts  for  the  old  obseryation  that  the  outdoor 
night  air  in  the  neighborhood  of  marshes  was  unhealthful  and 
produced  malaria. 

Diagnosis. — Physicians  often  make  a  diagnosis  of  malaria  in 
order  to  account  for  any  slight  chill  or  feyer  whose  cause  is 
obscure.  These  physicians  often  give  a  reputation  for  malaria 
to  districts  in  which  not  an  anopheles  mosquito  can  be  found. 
An  accurate  diagnosis  of  malaria  can  be  made  only  by  examin- 
ing the  blood  and  finding  the  malaria  organism. 

Control  and  Prevention, — Eyery  person  who  has  malaria  is 
a  breeder  of  malarial  organisms.  Some  persons  haye  chronic 
malaria  and  are  carriers  of  the  organisms  for  years.  A  health 
officer  would  naturally  consider  some  plan  of  keeping  mosquitoes 
away  from  every  malarial  case,  or  every  case  away  from  mos- 
quitoes, but  there  seems  to  be  no  practical  way  of  enforcing  the 
plan  or  of  compelling  the  chronic  carriers  to  rid  themselves  of 
the  organisms. 

Anopheles  mosquitoes  do  not  fly  far  or  high.  Locating 
dwellings  on  high  land  afl'ords  some  protection  against  malaria. 
Remaining  indoors  behind  screened  ^\dndow^s  at  night  gives 
almost  complete  protection,  for  the  anopheles  mosquitoes  are 
active  only  at  night. 

An  attack  of  malaria  does  not  produce  immunity,  but  it 
rather  gives  a  greater  susceptibility  to  another  infection.  A 
considerable  degree  of  immunity  is  produced  by  the  use  of  quinin, 
but  only  so  long  as  the  drug  is  used. 

The  most  practical  measure  of  protection  against  malaria  is 
the  destruction  of  anopheles  mosquitoes  in  their  breeding-places. 
A  health  officer  is  justified  in  conducting  an  extensive  anti- 
mosquito  campaign  on  the  ground  of  the  prevention  or  suppres- 
sion of  malaria. 

YELLOW  FEVER 

The  Virus. — Yeflow  fever  is  caused  by  a  virus  which  is  in 
the  blood  during  the  first  three  days  of  the  fever.  The  disease 
may  be  transmitted  by  the  inoculation  of  blood,  but  the  only 
way  in  which  the  disease  naturally  spreads  is  by  the  bite  of  a 


INSECT-BORNE  DISEASES  303 

mosquito  called  the  Aedcs  calopus,  formerly  called  the  Stego- 
myia  calopus.  A  mosquito  cannot  transmit  the  disease  until 
twelve  days  after  it  has  bitten  a  yellow  fever  patient,  but  it 
afterward  carries  the  yellow  fever  organisms  as  long  as  it  lives. 
The  disease  develops  five  days  after  a  person  has  been  bitten 
by  an  infected  mosquito. 

The  Mosquito. — The  Aedes  calopus  mosquito  is  small  and 
brilliantly  marked  with  silver.  It  breeds  in  small  collections  of 
water  around  houses,  and  is  not  found  more  than  a  quarter  of 
a  mile  from  human  dwellings.  It  is  a  weak  insect,  and  does  not 
fly  to  a  distance  of  many  yards.  It  is  killed  by  a  freezing  tem- 
perature, and  this  accounts  for  the  fact  that  an  epidemic  of  the 
disease  ceases  at  once  after  the  first  frost. 

Control  and  Prevention. — The  measures  for  the  control  and 
prevention  of  yellow  fever  are  directed  against  mosquitoes. 
Quarantine  or  isolation  is  unnecessary  except  to  prevent  mos- 
quitoes from  approaching  the  patient.  A  mosquito  screen  over 
each  patient  will  effectually  prevent  the  spread  of  the  disease. 
This  measure  cannot  always  be  carried  out  owing  to  the  exist- 
ence of  extremely  mild  cases  of  the  disease  which  are  not  dis- 
covered. 

The  destruction  of  all  mosquito  breeding-places  in  a  yellow 
fever  district  effectually  suppresses  an  epidemic  and  prevents 
the  development  of  the  disease  in  an  uninfected  district.  Anti- 
mosquito  work  is  one  of  the  most  essential  of  all  the  duties  which 
a  health  officer  performs  in  a  tropical  cHmate. 

TYPHUS  FEVER 

Typhus  fever  was  formerly  confused  with  typhoid  fever, 
but  its  onset  is  rapid,  and  an  abundant  red,  macular  eruption 


Fig.  23. — Method  of  transmission  of  typhus  fever. 

appears  from  the  third  to  the  fifth  dsiy.  The  eruption  gave  the 
disease  one  of  its  names — spotted  fever.  The  fever  runs  for 
about  two  weeks,  and  falls  suddenly  if  recovery  takes  place. 


304 


THE  HEALTH   OFFICER 


The  disease  is  caused  by  a  bacillus  which  is  transmitted  from 
person  to  person  by  the  bite  of  infected  body  lice  and  head  lice. 
It  was  formerly  common,  but  a  health  officer  will  probably  seldom 
or  never  see  a  case.  The  illness  called  Brill's  disease  is  a  mild 
form  of  typhus  fever  which  is  occasionally  recognized  in  cities. 
The  preventive  measures  against  t>'phus  fever  are  directed  al- 
most solely  against  lice  on  human  beings.  Their  extermination 
will  prevent  typhus  fever  as  effectually  as  the  extermination  of 
mosquitoes  will  prevent  malaria. 

PLAGUE 

Plague  is  a  highly  infectious  disease  which  is  caused  by  a 
bacterium   called   the   Bacillus   pestis.     There   are   three   main 


pmecT 


RMT  PICA 


Fig.  24. — Method  of  transmission  of  plague. 

forms  of  the  disease:  1,  the  bubonic,  in  which  there  are  enlarge- 
ments of  the  lymph-glands,  often  with  suppuration;  2,  a  septi- 
cemia; and  3,  the  pneumonic  form,  which  affects  the  lungs.  The 
bubonic  and  septicemic  forms  are  not  usually  directly  transmitted 
from  person  to  person  by  contact,  for  the  germs  are  not  excreted 
from  the  body;  but  the  bacilli  are  found  in  the  sputum  of  patients 
who  have  the  pneumonic  form,  and  the  disease  may  then  be 
transmitted  directly  from  one  person  to  another.     The  usual 


INSECT-BORNE   DISEASES  305 

method  of  transmitting  the  disease  is  by  means  of  fleas  that 
have  bitten  infected  persons  or  rats.  The  disease  affects  rats, 
squirrels,  and  other  rodents,  and  the  bacilli  are  usually  spread 
by  fleas  from  the  rats  that  have  died  from  the  disease. 

The  prevention  and  eradication  of  plague  depends  upon  a 
quarantine  of  all  cases,  and  the  extermination  of  rats,  ground 
squirrels,  and  other  animals  that  are  infected.  The  disease  is 
prevalent  in  southern  Asia.  It  frequently  appears  in  the 
United  States,  and  may  suddenly  spread  among  rats  at  any  time 
unless  they  are  kept  under  control. 


CIL\rTER  XXIX 

MISCELLANEOUS  DISEASES 

EYE  INFECTIONS 

Ophthalmia  Neonatorum. — A  health  officer  often  has  to  deal 
with  infectious  diseases  of  the  eye,  and  two  of  them,  ophthalmia 
neonatorum  and  trachoma,  are  reportable  in  New  York  State. 
Ophthahiiia  neonatorum,  or  inflammation  of  the  eyes  of  newborn 
children,  is  caused  by  an  infection  which  enters  the  eyes  at  birth, 
and  is  derived  from  the  mother.  It  is  a  severe  inflammation  of 
the  eyeball  and  Hds,  with  much  swelling  and  production  of  pus. 
It  often  produces  ulcers  on  the  cornea  which  leave  white,  opaque 
spots  on  healing.  It  is  the  cause  of  over  one-half  of  all  cases  of 
blindness.  The  disease  is  caused  by  two  kinds  of  infection, 
that  by  gonococci  and  that  by  streptococci.  The  two  forms 
are  very  much  alike,  and  can  be  told  apart  with  certainty  only 
by  an  identification  of  the  germs  in  the  pus.  Both  forms  are 
dangerous,  but  the  streptococcus  form  usually  runs  a  shorter 
course  and  its  eft'ects  are  less  severe  than  the  other. 

Ophthalmia  neonatorum  may  readily  be  prevented.  Its 
prevention  consists  in  cleanliness  during  birth,  and  in  treating 
the  eyes  of  the  child  immediately  after  birth  with  a  1  per  cent, 
solution  of  nitrate  of  silver  dropped  upon  the  cornea  while  the 
lids  are  held  open.  The  Department  of  Health  of  New  York 
State  supplies  physicians  and  midwives  with  outfits  of  the  silver 
nitrate  solution,  and  the  birth  report  has  a  blank  space  on  which 
the  physician  or  midwife  is  required  to  report  whether  or  not 
any  treatment  was  applied,  and  if  none  was  given,  the  reason 
why  it  was  not  must  be  stated. 

Pink-eye. — Children  often  have  an  acute  infection  of  the 
conjunctiva  called  pink-eye,  or  acute  contagious  conjunctivitis. 
It  produces  soreness  and  redness  which  lasts  a  week  or  two,  and 
leaves  no  permanent  injury.  The  disease  is  contagious,  and  is 
usually  caused  by  a  bacillus,  called  the  Koch-Weeks  bacillus, 
which  resembles  that  of  influenza.  The  disease  is  spread  by  the 
direct  transference  of  secretions  from  an  aft'ected  eye  to  the  eye 
of  another  person,  usually  by  handkerchiefs,  towels,  or  fingers. 
Its  prevention  consists  in  keeping  every  afTected  child  away  from 
others,  and  in  each  child  using  its  own  handkerchiefs  and  towels 
and  avoiding  those  used  by  other  persons. 
306 


MISCELLANEOUS   DISEASES  307 

Granulated  Lids. — There  is  a  common  eye  condition  in 
which  the  conjunctiva  appears  granular,  as  if  it  were  sprinkled 
with  sand.  The  granules  vary  in  size  from  those  which  are 
just  visible  to  those  as  large  as  small  pin-heads.  They  give 
rise  to  itching  and  smarting,  and  to  sensations  that  sand  is  in 
the  eye.  The  feelings  are  due  largely  to  the  friction  of  the 
granules  upon  the  sensitive  cornea.  The  danger  of  the  condi- 
tion depends  upon  the  extent  and  nature  of  the  trouble. 

Trachoma. — One  form  of  granulated  lids  is  infectious,  and 
is  called  trachoma.  There  is  doubt  regarding  its  bacteriology, 
but  a  bacillus  like  that  of  influenza  is  usually  associated  with  it. 
The  disease  is  spread  by  contact  with  excretions  from  the  eye 
of  an  affected  person.  It  runs  a  short  course,  and  tends  to 
increase  in  severity  and  not  to  disappear.  The  granulations 
extend  themselves  deep  into  the  conjunctiva  and  cause  a  destruc- 
tion of  the  tissues.  The  conjunctiva  heals  by  the  formation  of 
new  connective  tissue  or  scar  tissue,  which  contracts  and  draws 
the  lids  out  of  shape.  The  granulations  scrape  against  the 
cornea  and  produce  soreness  and  ulcerations.  Trachoma  is  dan- 
gerous to  sight,  and  if  it  is  neglected,  it  often  leads  to  blindness. 

Severe  cases  of  trachoma  can  be  cured  only  by  removing 
the  diseased  tissue  by  a  surgical  operation;  but  the  mild  cases 
may  be  cured  by  treating  them  daily  with  drops  of  1  :  2000 
solution  of  bichlorid  of  mercury  in  water.  The  exact  strength 
of  the  solution  may  be  varied,  but  it  must  be  sufficiently  strong 
to  produce  a  smarting  sensation  lasting  about  five  minutes. 
If  the  drops  are  applied  regularly,  the  secretions  of  the  eye  do 
not  seem  to  be  infectious,  and  the  affected  person  need  not  be 
placed  under  restrictions  or  excluded  from  school. 

Follicular  Conjunctivitis. — There  is  a  non-infectious  form  of 
granulated  lids,  called  follicular  conjunctivitis,  which  resembles  a 
mild  form  of  trachoma,  and  can  scarcely  be  distinguished  from 
it.  The  medical  examination  of  school  children  reveals  many 
cases  of  granulated  lids  whose  nature  cannot  be  determined  with 
certainty.  Eye  specialists  agree  that  there  is  a  disease,  follicular 
conjunctivitis,  which  is  not  contagious,  and  another  disease, 
trachoma,  which  is  contagious.  They  usually  agree  in  the  diag- 
nosis of  well-marked  cases,  but  they  often  disagree  over  cases 
that  are  mild.  A  health  officer  is  frequently  in  doubt  as  to  his 
duty  in  excluding  affected  children  from  school  and  in  requiring 
their  treatment.  The  experts  fortunately  agree  that  the  bi- 
chlorid drops  will  cure  follicular  conjunctivitis  as  well  as  tra- 
choma. The  health  officer  may,  therefore,  not  press  the  ques- 
tion of  naming  the  disease  so  long  as  the  bichlorid  treatment  of 
the  affected  children  is  carried  out. 


308  THE    HEALTH    OFFICER 

HOOKWORM  DISEASE 

The  Parasite. — Hookworm  disease  is  caused  by  worms  about 
^  inch  in  length  which  attach  themselves  to  the  wall  of  the 
intestine;  suck  blood  from  the  mucous  membrane,  and  probably 
inject  a  poison  into  the  system.  The  wonns  produce  eggs  which 
leave  the  body  with  the  intestinal  excretions  and  hatch  in  the 
soil.  The  young  worms  enter  the  body  through  the  skin,  usu- 
ally between  the  toes,  and  finally  reach  the  intestine,  where 
they  attach  themselves.  The  }'oung  worms  may  also  reach  the 
intestine  by  means  of  drinking-water.  The  spread  of  the  dis- 
ease is  due  principally  to  the  lack  of  privies  in  some  sections  of 
the  United  States,  and  to  the  resulting  pollution  of  the  soil 
with  human  excretions. 


^^=^ 


ifxncnoNS  IN  SOIL  sARt  recT 


Fig.  25. — Method  of  transmission  of  hookworm. 

The  Disease. — Hookworms  produce  a  great  anemia  and  a 
peculiar  yellow  color  of  the  skin.  They  do  not  cause  a  fatal 
illness,  but  their  victims  are  apathetic,  listless,  and  weak,  and 
are  unable  and  unwilling  to  work.  The  disease  is  common  in 
the  Southern  States  and  in  most  tropical  countries,  and  its 
eradication  is  a  great  problem  in  public  health.  A  person  who 
has  the  disease  may  be  cured  with  th^Tnol  in  doses  of  about 
20  grains,  taken  while  fasting  and  after  a  dose  of  Epsom  salts. 

Hookworm  disease  is  spread  by  means  of  the  intestinal  dis- 
charges.    The  means  of  prevention  are: 

1.  Provision  for  priiies  in  order  to  prevent  the  pollution  of 
the  soil  v.'ith  human  excretions  containing  the  eggs. 

2.  Wearing  shoes  in  order  to  protect  the  skin  against  the 
entrance  of  the  w^orms. 

3.  Cleanliness  of  the  hands  in  order  to  avoid  transferring  the 
worms  to  the  mouth. 


MISCELLANEOUS   DISEASES 


309 


4.  Boiling  drinking-water  in  order  to  kill  the  worms  that  may 
be  in  it. 

5.  The  adoption  of  general  sanitary  measures. 

The  prevention  of  hookworm  disease  is  largely  an  economic 
and  social  problem,  and  involves  the  expenditure  of  money  and 
effort  in  the  disposal  of  intestinal  excretions,  and  the  adoption 
of  higher  standards  of  social  hfe. 

TAPEWORM 

A  tapeworm  consists  of  a  head  and  a  long  series  of  broad, 
flat  segments.     The  head  is  about  the  size  of  a  very  small  pea. 


Fig.  26. — Method  of  transmission  of  tapeworm. 


and  is  fixed  to  the  mucous  membrane  of  the  intestine.  Its  only 
action  is  to  develop  the  segments.  Each  mature  segment  is 
about  ^  inch  square.  It  produces  fertile  eggs  which  are  ex- 
pelled from  the  human  body  with  the  intestinal  excretions. 
When  the  eggs  are  eaten  by  swine,  cattle,  or  fish,  they  develop 
into  new  heads  which  pass  into  the  blood-stream  and  lodge  in 
the  muscles.  A  head  develops  a  new  tapeworm  in  the  body  of 
a  person  who  eats  the  meat. 


310  THE   HEALTH   OFFICER 

The  prevention  of  tapeworm  consists  in  three  measures: 

1.  The  cure  of  the  affected  person. 

2.  The  disposal  of  human  excretions  in  such  a  way  that 
swine,  cattle,  or  fish  cannot  have  access  to  them. 

3.  Cooking  meat  and  fish,  or  thoroughly  salting  or  smoking 
that  which  is  to  be  eaten  raw. 

Tapeworm  is  not  classed  as  a  serious  disease,  and  it  is  seldom 
brought  to  the  ollicial  notice  of  a  health  officer.  The  possibility 
of  infecting  food  animals  is  an  argument  for  the  proper  disposal 
of  human  excretions. 

GLANDERS 

Glanders  is  a  disease  of  the  horse,  and  is  occasionally  com- 
municated to  stablemen.  It  is  caused  by  a  bacterium  called  the 
Bacillus  mallei.  The  disease  exists  as  nodules  and  ulcers  either 
in  the  nose  or  upon  the  skin.  The  existence  of  the  disease  may 
be  suspected  from  a  history  of  the  contact  of  the  patient  with 
diseased  animals.  It  may  be  confirmed  from  a  culture  which 
ma}'  be  taken  on  a  diphtheria  culture-tube,  and  by  animal 
inoculations. 

The  disease  in  horses  may  be  detected  by  the  mallein  test, 
which  is  similar  to  the  tuberculin  test.  It  consists  of  a  rise  in 
temperature  following  an  injection  of  killed  bacilli. 

The  control  of  glanders  in  New  York  State  is  vested  in  the 
Commissioner  of  Agriculture,  and  a  health  officer  may  call  on 
the  Agricultural  Department  for  assistance  when  the  disease  is 
suspected  in  horses. 

ANTHRAX 

Anthrax  was  the  first  disease  in  which  a  specific  micro- 
organism was  demonstrated.     The  bacilli  were  seen  in  the  blood 


Fig.  27. — Method  of  transmission  of  anthrax. 

in  1849,  and  were  obtained  in  pure  cultures  in  1877.     The  dis- 
ease affects  cattle,  and  is  occasionally  communicated  to  persons 


MISCELLANEOUS   DISEASES  311 

who  handle  the  skins  of  affected  animals.  The  bacilli  form  spores 
which  may  remain  alive  for  years.  The  symptoms  of  the  dis- 
ease are  indicated  by  its  old  name,  malignant  pustule.  It 
begins  as  a  vesicle,  or  pustule,  in  a  hard,  swollen  area  of  skin 
which  is  usually  located  on  the  hand  or  face  at  the  site  of  inocu- 
lation. The  vesicle  or  pustule  soon  dries,  leaving  a  black,  ne- 
crotic area.  The  bacilli  appear  in  the  blood  late  in  the  disease, 
but  they  may  usually  be  detected  in  a  culture  from  the  pustule. 
A  health  officer  may  make  a  culture  upon  a  diphtheria  culture- 
tube,  and  send  it  to  a  laboratory  for  examination;  or  the  pus- 
tule may  be  cut  out  and  sent  to  a  laboratory.  The  disease 
may  usually  be  detected  within  a  day  or  two  by  inoculation  of 
the  suspected  material  or  its  culture  into  mice. 

Anthrax  may  produce  a  disease  of  the  lungs  and  intestine, 
but  in  this  form  it  usually  goes  unrecognized  and  unsuspected 
unless  cultures  of  the  excretions  are  taken. 

The  treatment  of  anthrax  consists  in  the  cauterization  or 
excision  of  the  original  pustule  as  early  and  completely  as  pos- 
sible. The  measures  for  the  prevention  and  spread  of  the  dis- 
ease are  the  isolation  of  the  patient,  strict  antiseptic  precau- 
tions, and  the  sterilization  or  efficient  disposal  of  all  discharges 
and  excretions.     A  curative  serum  has  been  used  with  success. 

TRICHINOSIS 

Trichinosis  is  a  disease  of  human  beings  and  of  hogs,  rats, 
mice,  dogs,  and  other  animals.  Human  beings  catch  the  dis- 
ease by  eating  the  flesh  of  infected  hogs.  The  organism  of  the 
disease  is  a  worm  which  is  barely  visible  to  the  naked  eye.  The 
miniature  worms  are  found  coiled  in  the  muscles  where  they 
give  rise  to  tenderness  and  soreness  which  may  be  mistaken  for 
signs  of  rheumatism. 

When  a  person  or  animal  eats  the  infected  muscles,  the 
miniature  worms  are  set  free.  They  quickly  reach  their  full 
size  and  produce  young,  which  enter  the  blood-stream  and  thus 
reach  the  muscles.  Only  a  week  or  two  may  elapse  between  the 
time  of  eating  the  infected  meat  and  the  development  of  symp- 
toms. If  only  a  few  worms  reach  the  muscles,  there  may  be  no 
noticeable  symptoms;  but  if  there  are  many,  they  may  produce 
death.  The  prominent  symptoms  are  fever  and  muscular  pain, 
and  the  disease  is  often  mistaken  for  rheumatism  or  t}^hoid 
fever.  The  prevention  of  the  disease  in  man  consists  in  thor- 
oughly cooking  all  hog  flesh  that  is  eaten. 

Hogs  and  rats  catch  trichinosis  by  eating  offal  from  slaughter- 
houses  and  butcher  shops,  and   from   meats    discarded   from 


312  THE   HEALTH    OFFICER 

kitchens.     Hogs  could  readily  be  kept  free  from  the  disease  if 


PIG 


Fig.  28. — Method  of  transmission  of  trichinosis. 


rats  did  not  bring  it  to  them.     The  spread  of  the  disease  by  rats 
is  a  great  argument  for  their  extermination. 

LEPROSY 

Leprosy  is  caused  by  an  acid-fast  bacillus  which  resembles 
the  tubercle  bacillus.  It  produces  two  forms  of  disease.  An 
anesthetic  form  affects  the  nerv-es  and  produces  areas  which  are 
at  first  painful  and  later  anesthetic.  The  skin  over  the  areas  is 
usually  white.  The  other  form  of  leprosy  consists  of  skin  tu- 
bercles which  often  ulcerate  and  cause  a  loss  of  the  fingers  and 
toes.  The  bacilli  of  leprosy  are  given  off  with  the  excretions  of 
the  nose  and  of  the  ulcers.  The  disease  is  only  mildly  contagious 
in  the  United  States.  Its  prevention  consists  in  the  isolation  of 
the  cases. 


CHAPTER  XXX 

MENTAL  DEFECTS 

The  care  and  control  of  those  who  are  mentally  deficient  is 
within  the  scope  of  the  activities  of  a  health  officer.  Mental 
defects  concern  public  health  officials  for  the  following  reasons: 

1.  The  various  defects  are  disease  units;  they  are  classified 
and  defined;  and  their  cause  and  development  may  be  predicted 
with  a  considerable  degree  of  precision. 

2.  Many  of  the  defects  are  transmissible  from  one  person  to 
another. 

3.  They  are,  to  a  great  extent,  preventable  and  curable. 

4.  They  are  frequently  the  result  of  communicable  diseases, 
such  as  syphilis  or  tuberculosis. 

5.  They  are  often  the  result  of  social  and  economic  condi- 
tions, especially  those  leading  to  overwork,  malnutrition,  and 
disease. 

6.  They  are  frequently  the  underlying  causes  which  result 
in  disease,  prostitution,  disorder,  poverty,  and  crime. 

The  plea  that  an  offender  is  only  half-witted  is  no  longer  a 
valid  excuse  for  tolerating  unsanitary  conditions,  disorder,  and 
crime  in  a  community.  It  is  a  public  duty  of  officials  to  pre- 
vent or  remedy  mental  defects,  and  to  control  those  who  are 
unwilling  or  unable  to  control  themselves  or  those  under  their 
charge.  The  recognition  of  permanent  mental  defects  and  the 
control  of  the  mentally  deficient  are  largely  medical  problems, 
and  dealing  with  them  is  one  of  the  duties  of  a  health  officer  in 
his  capacity  as  the  medical  adviser  of  his  municipality.  The 
mental  defects  with  which  a  health  officer  has  to  deal  vary  from 
violent  insanity  to  mild  degrees  of  mental  insufficiency. 

Number  of  Cases. — Cases  of  mental  disorder  are  more 
numerous  than  they  are  popularly  supposed  to  be.  New  York 
State  supports  about  40,000  inmates  in  hospitals  for  the  insane, 
and  there  are  as  many  more  in  the  incipient  and  convalescent 
stages  of  insanity.  A  careful  survey  of  an  average  county  of 
115,000  inhabitants  revealed  1500  persons  whose  mental  ab- 
normalities were  sufficiently  marked  to  bring  them  in  ofl&cial 
contact  with  public  officers.  It  is  a  conservative  estimate  that 
at  least  1  per  cent,  of  the  population  require  public  care  and 
control,  and  are  a  burden  upon  society  on  account  of  mental 
abnormalities  and  deficiencies. 

313 


314  THE    HEALTH    OFFICER 

Causes. — The  principal  causes  of  mental  defects  are: 

1.  Heredity. 

2.  Environment. 

3.  Physical  disease. 

4.  Drugs. 

5.  Mental  strains. 

Heredity. — IMental  traits,  like  physical  characteristics,  are 
transmissible.  Children  tend  to  resemble  their  parents  both 
mentally  and  physically.  The  science  of  eugenics  is  concerned 
principally  with  the  relation  of  the  laws  of  heredity  to  the 
impro\-ement  of  the  mental  and  physical  condition  of  the  human 
race. 

A  fundamental  principle  in  heredity  and  eugenics  is  that 
the  peculiar  traits  which  distinguish  individuals  may  be  analyzed 
into  units  which  are  inherited  independently  of  one  another. 
Examples  of  physical  unit  characters  which  are  inherited  are 
the  color  of  the  eyes,  the  shape  of  the  nose,  the  complexion, 
tallness,  and  immunity  or  susceptibility  to  diphtheria.  Ex- 
amples of  mental  unit  characters  which  are  inherited  are  musical 
tastes,  mathematic  ability,  quickness  of  temper,  emotional  con- 
trol, deaf-mutism,  imbecihty,  and  Huntington's  chorea. 

Each  person  embodies  a  complex  collection  of  unit  char- 
acteristics. The  mental  and  physical  nature  of  an  individual  is 
a  compound  of  many  units  which  often  overlie  and  obscure  one 
another.  A  trait  may  apparently  be  absent  when  it  is  domi- 
nated by  another  trait.  If,  for  example,  a  person  inherits  both 
quickness  of  temper  and  emotional  control,  the  quickness  of 
temper  may  not  be  apparent  to  an  observer.  The  detection 
and  determination  of  all  the  unit  characters  of  an  individual 
are  difficult  unless  a  complete  ancestral  history  of  all  the  parents 
and  grandparents  for  many  generations  is  available. 

Mendel's  Law. — When  both  parents  possess  a  particular  unit 
character,  all  their  children  will  inherit  it;  and  if  these  children 
marry  persons  having  the  character,  all  their  descendants  will 
have  it,  and  we  say  that  the  strain  of  blood  is  pure.  When  only 
one  parent  has  a  unit  character,  the  children  will  be  of  mixed 
blood,  and  when  they  intermarry,  one-quarter  of  their  descend- 
ants will  have  the  unit  character  in  full  degree;  one-quarter  will 
lack  it  entirely;  and  two-quarters  will  be  of  mixed  blood.  A 
statement  of  the  proportions  in  which  descendants  of  mixed 
blood  show  unit  characters  is  called  Mendel's  law. 

An  illustration  of  Mendel's  law  is  the  proportion  of  black  to 
white  chickens  that  may  be  expected  when  a  white  chicken  is 
crossed  with  a  black  one,  and  succeeding  generations  are  in- 
tercrossed.    Since  black  is  due  to  a  pigment  and  white  to  its 


MENTAL  DEFECTS  315 

absence,  chickens  of  mixed  blood  will  be  black  and  indistinguish- 
able from  the  blacks  of  pure  blood.  The  possible  combinations 
of  black  and  white  in  a  pair  of  chickens  which  have  both  black 
and  white  strains  in  them  is  shown  by  the  following  diagram: 

male:  female 

black      ::: fo  — j  biacK 

to  ^"^ 

to 

^^  white 


Diagram  illustrating  the  hereditary  transmission  of  color  in  fowls. 

Each  male  and  female  contains  a  unit  character  of  white  and 
one  of  black.  If  the  white  character  of  one  parent  unites  with 
the  white  of  the  other,  the  offspring  will  be  a  pure  strain  of 
white  with  no  trace  of  black. 

If  the  black  character  unites  with  the  black,  the  offspring 
will  be  pure  black. 

There  are  two  chances  that  the  black  of  one  will  unite  with 
the  white  of  the  other,  and  the  offspring  be  of  mixed  strains. 
The  result  is  that  one-quarter  of  the  chickens  will  be  of  a  pure 
strain  of  black,  one-quarter  of  a  pure  strain  of  white,  and  two- 
quarters  of  a  mixed  strain  of  black.  Experience  demonstrates 
that  the  law  usually  holds  good. 

Mendel's  law  explains  the  occurrence  of  abnormal  mental 
conditions  among  the  descendants  of  parents  having  a  strain  of 
mental  abnormality.  The  possible  combinations  of  normal  and 
abnormal  elements  is  shown  by  the  following  diagram: 

FATHETR  MOTHER 

pormal        to    =.  normal 


abnormal       :— to    — ^  abnormal 

Diagram  illustrating  the  hereditary  transmission  of  mental  traits. 

When  persons  with  a  strain  of  mental  abnormahty  marry 
others  with  a  similar  strain,  the  result  will  be  that  one-quarter 
of  the  descendants  will  be  normal  without  a  trace  of  abnormahty; 
one-quarter  will  be  abnormal  to  a  great  degree,  and  two-quarters 
will  show  lesser  degrees  of  abnormality. 

The  operation  of  Mendel's  law  in  the  inheritance  of  mental 
traits  is  as  certain  and  exact  as  it  is  in  chicken  breeding.  This 
law  of  heredity  justifies  strong  measures  for  the  control  of  mar- 
riage among  defectives,  and  the  prevention  of  procreation  among 


316  THE  HEALTH   OFFICER 

those  who  are  mentally  deficient.  It  is  also  a  source  of  en- 
couragement, for  there  is  an  inheritance  of  mental  traits  which 
are  normal  and  desirable  as  well  as  of  those  which  are  abnormal 
and  undesirable.  It  furthermore  accounts  for  the  fact  that  one 
member  of  a  family  may  be  nomial  and  highly  intelligent  and 
have  brothers  and  sisters  who  are  abnomial  or  feeble-minded. 

Environment. — Hereditary  traits  are  implanted  and  fixed  in 
the  genn  cell  of  an  individual  at  the  time  of  conception,  but  the 
development  of  the  traits  is  aft'ected  to  a  profound  degree  by 
environment  and  training.  It  is  often  a  question  whether  a 
trait  is  the  result  of  heredity  or  of  environment.  Proper  en- 
vironment and  training  may  cause  the  development  of  normal 
traits  w'hen  hereditary  influences  tend  to  the  development  of 
traits  which  are  abnormal  and  undesirable.  An  efficient  teacher 
must  consider  both  the  history  of  the  parents  and  also  the  child's 
home-hfe  and  surroundings.  Hereditary  and  congenital  weak- 
ness or  abnormality  may  be  so  great  that  no  amount  of  care  and 
training  will  bring  the  individual  up  to  a  normal  standard; 
and,  on  the  other  hand,  hereditary  strength  of  mentahty  and 
character  may  be  so  great  that  an  indi\-idual  may  develop  nor- 
mally amid  surroundings  and  influences  that  are  evil  and  weak- 
ening to  both  mind  and  body. 

Two  fundamental  principles  in  the  prevention  of  mental 
abnormalities  and  w^eaknesses  are:  1,  the  protection  of  the 
abnormal  person  from  influences  w-hich  tend  to  arouse  or  pro- 
duce the  abnormal  state  of  mind;  and  2,  training  to  develop  the 
mind  along  normal  lines.  Nearly  every  person  who  is  feeble- 
minded or  abnormal  is  normal  in  many  respects.  Most  in- 
mates of  institutions  for  the  insane  and  feeble-minded  may  lead 
normal  lives  so  long  as  they  remain  under  the  influence  and 
protection  of  the  institution  or  of  a  competent  person  outside 
of  it. 

Physical  Disease. — A  mental  abnormality  or  defect  may  be 
the  direct  result  of  a  physical  disease  or  defect.  The  delirium 
of  an  acute  fever  is  the  result  of  poisons  developed  in  the  body. 
Syphilis  is  frequently  the  cause  of  insanity  and  of  congenital 
feeble-mindedness. 

Feeble-mindedness  in  the  blind  or  deaf  is  often  the  direct 
result  of  eye  or  ear  defects  dating  from  infancy.  These  persons 
may  be  feeble-minded  merely  because  they  are  unable  to  receive 
normal  mental  impressions.  Their  minds  develop  normally 
when  they  are  taught  to  receive  mental  impressions  through  the 
senses  which  are  normal. 

The  most  frequent  causes  of  blindness  and  deafness  are  in- 
fectious diseases,  such  as  scarlet  fever,  measles,  and  syphilis, 


MENTAL  DEFECTS  317 

which  are  directly  under  the  control  of  the  health  officer.  The 
care  of  the  blind  and  deaf  children  is  a  phase  of  the  child  welfare 
and  school  inspection  work  of  the  health  officer. 

Drugs. — Insanity,  feeble-mindedness,  and  abnormal  mental 
states  may  be  the  result  of  poisoning  by  drugs,  especially  mor- 
phin,  cocain,  and  alcohol,  when  they  are  used  habitually.  Other 
habit-forming  drugs  are  chloroform,  headache  cures,  such  as 
phenacetin,  aspirin,  and  bromocaffein,  and  hypnotics,  such  as 
choral,  sulfonal,  and  paraldehyd.  The  detection,  control,  and 
treatment  of  drug  habitues  is  within  the  scope  of  the  activities 
of  a  health  officer,  especially  in  a  rural  district. 

Mental  Strains. — There  are  varying  degrees  of  temper  of 
mind  as  there  are  of  steel.  Some  minds  are  unable  to  with- 
stand a  prolonged  strain  or  severe  shock,  while  others  can  en- 
dure the  most  severe  strains  and  shocks,  as  in  violent  and 
prolonged  bombardments.  Fine  mental  temper  and  control 
may  be  hereditary,  or  a  considerable  degree  may  be  acquired  by 
training. 

The  common  forms  of  mental  strains,  such  as  financial 
worries,  overwork,  and  loss  of  friends,  usually  produce  the 
premonitory  symptom  of  inability  to  sleep.  Some  persons  be- 
come dull  and  sleepy  when  they  endure  mental  strains;  and 
they  recover  their  normal  state  of  mind  after  sleep.  Mental 
strains  cause  other  persons  to  become  excited  and  sleepless,  and 
it  is  these  who  break  down  under  mental  stress. 

Mental  strains  often  result  from  the  concentration  of  the 
mind  upon  a  single  object  day  after  day.  The  best  mental 
relaxation  comes  from  a  complete  change  of  work,  even  though 
the  second  line  of  thought  requires  as  much  mental  effort  as  the 
first.  There  is  a  very  great  health  value  in  a  favorite  sport,  or 
amusement,  or  hobby.  A  health  officer  can  do  excellent  pubhc 
health  service  by  promoting  organized  games  and  sports  in  a 
community. 

Classification  of  Abnormal  Mental  States.^The  standard  of 
the  classification  of  mental  abnormalities  may  be  either  medical 
or  sociologic.  The  medical  list  of  abnormalities  is  lengthy  and 
complicated.  A  health  officer  is  expected  to  make  only  a  gen- 
eral diagnosis  and  to  classify  the  case  in  a  proper  medical  group 
in  order  to  place  the  patient  in  the  proper  institution,  or  to 
secure  the  proper  supervision  and  control  over  the  case.  Four 
groups  of  abnormalities  which  are  of  special  interest  to  a  health 
officer  are: 

1.  The  psychoses,  or  what  are  popularly  called  insanities. 
Cases  in  this  group  are  treated  in  special  hospitals  and  institu- 
tions for  the  insane. 


318  THE    HEALTH    OFFICER 

2.  Simple  dementia  of  old  age.  The  cases  of  this  group  may 
properly  be  sent  to  almshouses  or  be  treated  in  their  homes. 

3.  Disorders  due  to  drug  habits.  Greater  provision  is  neces- 
sary for  the  control  and  care  of  drug  habitues. 

4.  Feeblc-mindedness.  Cases  of  mental  deficiency  are  sent 
to  special  institutions  and  reformatories,  and  are  often  improp- 
erly sent  to  jail.  The  prevention  of  the  condition  is  within  the 
scope  of  infant  welfare  work  and  the  medical  inspection  of  school 
children. 

A  health  officer  will  frequently  use  a  sociologic  classification 
based  on  the  relation  of  the  patients  to  their  families  and  to 
society.  A  practical  classification  is  that  of  the  British  Royal 
Commission  on  the  care  and  control  of  the  feeble-minded,  and  is 
as  follows: 

1.  Persons  of  unsound  mind.  These  are  persons  who  require 
care  and  control  owing  to  a  disorder  of  the  mind,  and  are  con- 
sequently incapable  of  managing  themselves  or  their  affairs. 
This  class  comprises  those  who  are  popularly  called  the  insane 
or  lunatics;  but  it  excludes  those  in  the  following  classes. 

2.  Persons  mentally  infirm.  These  are  persons  who  through 
old  age  or  the  decay  of  their  faculties  are  incapable  of  managing 
themselves  or  their  families. 

3.  Idiots.  These  are  persons  who  are  so  deeply  defective  in 
mind  from  birth  or  from  an  early  age  that  they  are  unable  to 
guard  themselves  from  common  physical  dangers.  Their  men- 
tahty  is  that  of  helpless  infants. 

4.  Imbeciles.  These  are  persons  who  are  capable  of  guard- 
ing themselves  from  common  physical  dangers,  but  are  incap- 
able of  earning  their  own  living  by  reason  of  mental  defects 
existing  from  birth  or  from  an  early  age. 

5.  Feeble-minded.  These  are  persons  who  may  be  capable  of 
earning  a  li\ing  under  favorable  circumstances,  but  on  account 
of  mental  defects  existing  from  birth  or  from  an  early  age  they 
are  incapable  of  competing  on  equal  terms  with  their  normal 
fellows,  or  of  managing  themselves  or  their  affairs  with  ordinary 
prudence.  This  class  includes  the  morons,  or  those  whose  men- 
tality is  above  that  of  an  imbecile,  but  below  that  of  a  normal 
person  of  low  intelligence. 

6.  jMoral  imbeciles.  These  are  persons  who  from  an  early 
age  display  some  mental  defect  coupled  with  strong  vicious  or 
criminal  propensities  on  which  punishment  has  httle  or  no  deter- 
rent effect. 

7.  Epileptics  who  are  also  mentally  defective. 

8.  Inebriates  and  drug  habitues,  who  are  also  mentally 
defective. 


MENTAL  DEFECTS  319 

9.  The  deaf  and  dumb  or  blind  who  arc  also  mentally  de- 
fective. 

All  classes  of  cases  of  mental  disorder  frequently  come  to 
the  attention  of  the  health  ofhcer.  He  has  official  duties  to 
perform  in  relation  to  the  insane  and  the  feeble-minded,  and  is 
indirectly  interested  in  the  other  classes  of  cases.  The  aged, 
the  mentally  infirm,  idiots,  and  imbeciles  obviously  require  care 
which  is  usually  given  by  guardians  and  overseers  of  the  poor. 
The  moral  imbeciles  come  under  the  control  of  police  officers. 
Arrangements  for  the  care  of  epileptics,  inebriates,  the  deaf 
and  dumb,  and  the  blind  are  usually  made  through  charitable 
and  philanthropic  workers. 

Evidences  of  Mental  Abnormality. — Cases  of  mental  disorder 
and  feeble-mindedness  usually  come  to  the  attention  of  the 
health  officer  on  account  of  conduct  which  would  be  considered 
disorderly  or  foolish  if  it  were  the  act  of  a  normal  person.  There 
is  often  difficulty  in  determining  the  motive  for  an  action  and 
its  interpretation  when  the  person  performing  it  is  apparently 
normal  and  yet  obstinately  independent  and  disregardful  of 
public  sentiment. 

Some  of  the  gross  evidences  of  abnormaUty  are  as  follows: 

Retardation  at  school. 

Truancy,  unruliness,  cruelty,  etc. 

Sex  immorality. 

Disorderly  conduct. 

Criminal  tendency. 

Vagrancy. 

Dependency. 

Inebriety. 

Drug  habits. 

Domestic  maladjustment. 

Incompetency,  especially  among  housewives. 

Improper  guardianship  of  children. 

Unsanitary  conditions  at  home. 

The  classes  of  persons  in  which  a  health  officer  may  expect 
to  find  numerous  cases  of  mental  disorder  and  feeble-mindedness 
are  as  follows: 

1.  Those  under  arrest. 

2.  Backward  children  in  school. 

3.  Persons  known  to  be  public  nuisances. 

4.  Hermits. 

5.  Drunkards. 

6.  Prostitutes. 

A  health  officer  usually  learns  of  the  probable  existence  of 
mental  abnormaHty  from  the  following  groups  of  persons: 


320  THE   HEALTH    OFFICER 

1.  Teachers. 

2.  Neighbors  who  are  annoyed  by  the  affected  persons. 

3.  Overseers  of  the  poor. 

4.  Ministers  and  church  workers. 

5.  Workers  in  charitable  and  philanthropic  societies. 

6.  Physicians  who  seek  assistance  in  sending  cases  to  institu- 
tions. 

The  Insane. — Insanity  is  the  principal  mental  disorder  with 
which  a  health  offtcer  has  to  deal.  One  of  his  duties  is  to  secure 
the  proper  control  and  care  of  insane  persons  whose  guardians 
are  unable  or  unwilling  to  care  for  them  at  home.  Treatment 
in  special  hospitals  is  recognized  as  the  best  means  of  caring  for 
the  insane,  and  as  the  only  practical  means  in  most  cases.  Many 
insane  persons  accept  hospital  treatment  voluntarily  when  the 
nature  and  curability  of  their  disorder  is  explained  to  them. 
Most  cases  of  insanity,  like  those  of  tuberculosis,  recover  or 
are  arrested  in  de\-elopment  when  they  receive  proper  care  and 
treatment  in  their  early  stages.  Recognition  of  the  curability 
of  mental  disorders  when  they  are  treated  early  is  a  great  factor 
in  overcoming  popular  prejudices  against  the  acceptance  of 
hospital  treatment  in  the  early  stages  of  the  disorder.  The 
ideal  method  in  dealing  with  insanity,  as  with  tuberculosis,  is 
to  diagnose  and  treat  the  cases  in  their  incipiency  while  the  dis- 
order is  curable.  Many  high-class  sanitariums  and  health  re- 
sorts are,  in  reality,  institutions  for  the  treatment  of  those  who 
would  be  in  insane  hospitals  if  they  did  not  have  the  financial 
means  to  secure  private  treatment  and  care. 

Evidences  of  Insanity. — The  principal  direct  evidences  of 
insanity  are  confusion  of  mind,  delusions,  illusions,  and  hallu- 
cinations. 

Evidences  of  mental  confusion  are: 

Mistakes  in  familiar  names,  places,  and  dates. 

Failure  of  memory  for  recent  events. 

Inability  to  concentrate  the  mind  on  a  subject. 

Wandering  of  thought  from  one  subject  to  another. 

Emotional  excitement  or  depression. 

Marked  change  in  mentality  or  behavior. 

Delusions  are  marked  errors  of  judgment.  Common  ex- 
amples of  delusions  are  those  of  the  following  conditions: 

Sudden  gain  of  wealth  or  loss  of  property. 

The  possession  of  unlimited  power  or  the  onset  of  great 
weakness. 

Suspicion  of  near  relatives  and  close  friends. 

Visionary  plans  and  ideas,  such  as  the  invention  of  an  auger 
to  bore  a  square  hole. 


MENTAL  DEFECTS  321 

Changed  identity,  such  as  the  belief  of  being  President  of 
the  United  States. 

Ideas  of  being  inspired  by  spirits. 

Fixed  beliefs  in  being  persecuted  by  personal  enemies. 

Illusions  are  erroneous  interpretations  of  impressions  on  the 
senses.  Voices  of  persons  talking  on  the  street  may  be  inter- 
preted as  the  calls  of  spirits;  the  flicker  of  a  light  as  the  signal 
of  an  enemy;  or  the  bad  taste  of  a  coated  tongue  as  that  of 
poison  in  the  patient's  food. 

Hallucinations  are  imaginary  sense  impressions  for  which 
there  are  no  physical  bases.  Common  examples  of  hallucina- 
tions are  visions  of  angels  or  devils  in  the  patient's  room,  and 
hearing  the  voices  of  dead  persons. 

Lesser  degrees  of  mental  confusion,  delusions,  illusions,  and 
hallucinations  occur  in  normal  persons.  Many  persons,  for 
example,  have  illusions  and  hallucinations  of  seeing  ghosts  at 
night.  The  visions  of  the  insane  are  similar  to  the  dreams  of 
normal  persons;  but  the  difference  is  that  a  normal  person 
realizes  their  fantastic  character  with  the  coming  of  daylight  or 
after  an  explanation  of  the  phenomena;  while  the  insane  are 
unconvinced  by  argument  or  explanation,  but  believe  themselves 
to  be  right  and  everybody  else  wrong. 

Commitment  to  Hospitals. — The  laws  of  the  several  states 
provide  for  the  legal  committment  of  insane  persons  to  hos- 
pitals when  they  will  not  go  voluntarily  or  do  not  have  sufficient 
intelligence  to  do  so.  The  laws  of  New  York  State  charge  the 
health  officer,  jointly  with  the  superintendent  of  the  poor  and 
the  town  overseer,  with  the  duty  of  caring  for  insane  indigent 
persons.  It  also  charges  the  health  officer  with  the  duty  of 
examining  and  caring  for  any  person  under  arrest  who  is  ap- 
parently insane  (Insanity  Law,  Section  87).  It  is  important 
that  the  proper  legal  steps  for  commitment  of  irresponsible 
cases  be  followed  in  order  that  the  patients  may  be  held  for 
treatment  for  a  sufficient  time  until  their  mentality  can  be 
restored,  and  in  order  that  prejudiced  friends  may  not  interfere 
with  the  treatment. 

When  a  health  officer  receives  a  report  of  a  case  of  suspected 
insanity,  his  first  duty  is  to  see  the  patient  receives  proper  care 
and  attention,  at  pubhc  expense  if  necessary,  until  his  mental 
condition  can  be  .determined.  It  is  the  intent  of  the  law  that 
a  suspected  person  shall  not  be  confined  in  a  jail;  but  when  a 
homeless  patient  is  violent  and  destructive,  there  may  be  no 
other  place  in  which  he  may  be  made  comfortable.  If  a  jail  must 
be  used  as  a  detention  place,  the  invariable  rule  is  that  an  efficient 
attendant  shall  remain  in  the  room  with  the  patient  at  all  times. 


322  THE   HEALTH    OFFICER 

The  next  duty  of  a  health  oflker  is  to  secure  the  commit- 
ment of  the  patient  to  a  hospital.  This  is  a  legal  procedure  that 
is  equivalent  to  a  charge,  trial,  and  sentence  in  a  court.  The 
commitment  papers  are  on  blanks  provided  for  that  purpose, 
and  consist  of  three  parts,  as  follows: 

1.  An  application  by  a  proper  person  that  the  patient  be 
examined  and  committed. 

2.  A  record  of  the  evidence  of  the  insanity  of  the  patient. 

3.  A  formal  order  by  a  judge  committing  the  patient  to  a 
particular  hospital. 

An  application  for  commitment  may  be  made  by  a  relative, 
or  by  a  guardian  or  intimate  friend,  or  by  an  overseer  of  the 
poor,  or  by  an  officer  in  charge  of  the  patient.  It  must  contain 
a  sworn  statement  of  the  patient's  acts  which  indicate  insanity. 

The  evidence  of  insanity  consists  of  the  record  of  an  examina- 
tion made  by  two  physicians  who  are  legally  qualified  by  law  to 
act  as  examiners  in  lunacy.  A  health  ofticer  may  act  as  one  of 
the  examiners  in  New  York  State  The  evidence  is  of  the 
same  nature  as  that  given  in  a  law  court.  It  must  be  sufficient 
to  justify  a  verdict  of  insanity  if  the  case  should  come  to  trial, 
as  many  of  them  do.  The  record  will  usually  contain  informa- 
tion along  four  lines,  as  follows: 

1.  The  physical  condition  of  the  patient. 

2.  What  the  patient  did  in  the  presence  of  the  examiners, 

3.  What  the  patient  said  to  the  examiners. 

4.  Statements  made  by  other  persons  regarding  the  actions 
of  the  patient. 

The  most  convincing  evidences  of  insanity  are  fixed  delusions, 
illusions,  and  hallucinations.  If  the  existence  of  any  of  these 
can  be  established,  a  court  will  usually  accept  it  as  positiv-e 
evidence  of  insanity. 

After  the  application  and  the  examination  blanks  have  been 
made  out,  the  papers  are  taken  to  a  judge  for  his  official  action. 
The  judge  will  consider  the  application  and  the  medical  evidence 
as  he  would  the  charge  and  testimony  in  a  law  suit.  If  he  finds 
them  sufficient,  he  will  sign  an  order  of  commitment. 

If  there  is  opposition  to  the  commitment,  the  judge  will 
hold  a  trial  of  the  case.  The  procedure  in  the  trial  will  be  the 
same  as  that  in  other  law  suits.  If  the  case  comes  to  trial,  the 
health  officer  and  medical  examiners  must  be  prepared  to  un- 
dergo cross-examinations  regarding  the  evidence  which  they 
recorded  on  the  commitment  blank. 

It  is  desirable  that  patients  shall  be  informed  of  their  mental 
condition,  of  the  imaginary  nature  of  their  delusions  and  illu- 
sions, and  of  the  probability  of  their  speedy  improvement  or 


MENTAL  DEFECTS  323 

cure;  and  it  is  also  desirable  that  they  be  told  that  they  will  be 
taken  to  a  hospital  for  the  treatment  of  mental  diseases.  When 
this  information  is  imparted  tactfully  and  firmly,  patients  usu- 
ally consent  to  go  to  the  hospital.  Nothing  is  gained  by  con- 
cealing the  nature  of  the  disorder  or  by  deceiving  them  regard- 
ing the  treatment.  It  is  well  to  talk  to  insane  patients  as  if 
they  were  of  sound  mind.  Nearly  every  insane  person  can 
reason  normally  along  most  lines  of  thought,  and  can  be  led  and 
directed  like  patients  in  a  delirium  of  fever. 

If  force  must  be  used  in  transferring  an  insane  person  to  a 
hospital,  two  or  three  strong  attendants  can  hold  and  carry 
the  patient  in  such  a  manner  that  only  a  minimum  amount  of 
struggling  is  possible.  The  halfway  use  of  force  permits  strug- 
gling, arouses  fear,  and  often  results  in  physical  injury;  but  a 
resisting  patient  will  usually  yield  quickly  to  firm,  efficient  force 
which^produces  no  physical  discomfort. 

Besides  the  full  form  of  legal  commitment,  the  laws  of  New 
York  State  provide  three  other  methods  by  which  a  health  officer 
can  place  an  insane  patient  in  a  hospital: 

1.  A  patient  may  go  to  a  hospital  voluntarily.  It  is  de- 
sirable that  patients  in  the  premonitory  stages  of  mental  dis- 
order should  accept  preventive  treatment  which  is  analogous 
to  the  treatment  of  diphtheria  with  antitoxin  in  the  earliest 
stage  of  the  disease. 

2.  If  no  judge  can  be  reached  and  the  case  requires  immediate 
treatment,  a  health  officer  may  send  the  case  to  a  hospital  with 
a  copy  of  the  application  and  medical  examination.  The  super- 
intendent can  then  legally  hold  the  case  for  ten  days  while 
waiting  for  a  judge  to  sign  the  commitment  papers. 

3.  If  a  case  involves  immediate  danger  to  life  or  property, 
a  health  officer  may  make  arrangements  with  the  superintendent 
of  a  hospital  to  receive  the  case  without  any  papers  except  the 
health  officer's  formal  statement  regarding  the  emergency  char- 
acter of  the  case.  The  formal  papers  are  then  to  be  made  out 
as  soon  as  possible. 

Clinics  for  Mental  Disorders. — Clinics  are  needed  for  the 
treatment  of  cases  of  mental  disorder  which  are  not  sufficiently 
grave  to  require  their  entrance  into  a  hospital,  and  yet  need 
oversight  and  ad\'ice.  These  cases  are:  1,  those  discharged  from 
hospitals;  and  2,  those  who  are  able  to  work  and  to  control  their 
actions  in  society.  Those  clinics  which  have  been  established 
are  well  patronized  and  are  proving  a  great  success  in  the  pre- 
vention of  grave  forms  of  mental  disorders.  Their  establish- 
ment in  centers  available  to  rural  districts  is  a  necessary  develop- 
ment in  public  health  work. 


324:  THE   HEALTH   OFFICER 

The  Feeble-minded. — Some  weak-minded  persons  are  adults 
who  have  developed  normally,  and  who  suffer  from  a  simple 
decay  of  all  their  faculties;  but  the  term  "feeble-minded"  is 
restricted  to  those  who  are  in  that  condition  from  birth.  Feeble- 
minded men  and  women  have  the  physical  bodies  of  adults,  but 
the  minds  of  children.  This  class  of  persons  are  of  special  in- 
terest to  the  health  officer  on  account  of  their  close  relation  to 
disease,  poverty,  prostitution,  and  crime,  and  to  all  the  prob- 
lems connected  with  these  conditions. 

The  degree  of  mental  deficiency  is  expressed  by  the  age  at 
which  a  noniial  child  would  hsLxe  the  mentality  of  the  affected 
person.  Those  whose  mental  development  is  that  of  one-year- 
old  infants  are  called  idiots.  Those  with  the  mentaUty  of 
four-year-old  children  are  called  imbeciles.  Those  whose  mental 
development  is  that  of  children  from  five  to  fourteen  years  of 
age  are  called  morons.  The  class  of  morons  are  subcjivided 
into  low,  middle,  and  high  grade. 

Standard  tests  for  feeble-mindedness  are  those  known  as  the 
Binet  tests.  They  consist  of  questions  and  directions  corre- 
sponding to  the  ability  of  average  children  at  various  ages. 
A  short,  simple  form  of  the  tests  which  can  be  used  by  a  health 
officer  is  as  follows: 

TJircc  Years 

1.  Point  to  your  eyes;  nose;  mouth. 

2.  What  is  this?     Shows  a  key;  knife;  penny;  watch. 

3.  Are  you  a  boy  or  a  girl? 

4.  What  is  your  name? 

Four  Years 

5.  Counts  four  pennies. 

6.  What  must  vou  do  when  vou  are  sleepy?  cold?  hungry? 

7.  Repeats  4739;  2854;  726l'. 

8.  Repeats,  "We  are  going  to  have  a  good  time  in  the  coun- 
try." 

Five  Years 

9.  Recognizes  red,  yellow,  blue,  green. 

10.  Defines  in  terms  of  use,  chair,  horse,  fork,  pencil,  doll. 

11.  Carries  out  the  order.  "Put  this  key  on  the  chair,  shut 
the  door,  and  bring  me  the  bo.x  from  the  chair." 

12.  Gives  age. 

Six  Years 

13.  Which  is  your  right  hand?     Your  left  ear? 

14.  Counts  13'. 

15.  Knows  nickel,  penny,  quarter,  dime. 

16.  Is  this  morning;  or  afternoon? 


MENTAL  DEFECTS  325 

Seven    Years 

17.  How  many  fingers  on  the  right  hand?  left  hand?  both 
hands? 

18.  Repeats  31759;  42385;  98176. 

19.  Tells  difference  between  a  fly  and  a  butterfly;  paper  and 
cloth;  wood  and  glass. 

20.  Knows  the  days  of  the  week. 

Eight    Years 

21.  Counts  from  20  to  1. 

22.  Tells  the  similarity  between  wood  and  coal;  an  apple  and 
a  peach;  a  ship  and  an  automobile. 

23.  Defines  better  than  in  terms  of  use,  chair,  horse,  fork, 
pencil,  doll. 

24.  Recognizes  six  coins. 

Nine  Years 

25.  Gives  date. 

26.  Gives  the  months  of  the  year. 

27.  Makes  change,  10  —  4,  15  —  12,  25  —  4. 

28.  Repeats  backward  6528,  4937,  3629. 

Ten  Years 

29.  Recognizes  the  absurdities  in  the  following  statements: 
A  man  said:  'T  know  a  road  from  my  house  to  the  city  which  is 
downhill  all  the  way  to  the  city  and  downhill  all  the  way  back 
home." 

An  engineer  said  that  the  more  cars  he  had  on  his  train  the 
faster  he  could  go. 

Yesterday  the  police  found  the  body  of  a  girl  cut  into  eigh- 
teen pieces.     They  believe  that  she  killed  herself. 

There  was  a  railroad  accident  yesterday,  but  it  was  not  very 
serious.     Only  48  people  were  killed. 

A  bicycle  rider,  being  thrown  from  his  bicycle  in  an  accident, 
struck  his  head  against  a  stone  and  was  instantly  killed.  They 
picked  him  up  and  carried  him  to  the  hospital,  and  they  do  not 
think  he  will  get  well  again. 

30.  Draws  designs. 

31.  What  ought  you  to  say  when  some  one  asks  your  opinion 
about  a  person  you  don't  know  very  well? 

What  ought  you  to  do. before  undertaking  (beginning)  some- 
thing very  important? 

Why  should  we  judge  a  person  more  by  his  actions  than  by 
his  words? 

32.  Repeats  374859,  421746. 


326  THE   HEALTH   OFFICER 

Over  Ten   Years 

a.  Uses  three  words  in  one  sentence:  money,  river,  New 
York. 

34.  Repeats.  "Walter  likes  very  much  to  go  on  visits  to  his 
grandmother,  because  she  always  tells  him  many  funny  stories." 

vS5.  Names  60  words  at  random  in  three  minutes. 

36.  A  person  who  was  walking  in  the  forest  near  here  suddenly 
stopped  much  frightened  and  hastened  to  the  nearest  police 
station  and  reported  that  he  had  seen  hanging  from  a  limb  of 
a  tree  a what? 

When  a  rapid  examination  of  an  adult  is  to  be  made,  the 
examiner  may  use  tests  nmnbered  4,  18,  20,  21,  26,  27,  32,  and 
35,  and  also  the  following  general  questions: 

When  is  Christmas?     Thanksgi\ing? 

When  is  your  birthday?     In  what  \-ear  were  3-ou  born? 

Who  is  the  President  of  the  United  States?  Who  was  the 
first  President? 

Who  was  the  Civil  War  President? 

What  countries  are  at  war? 

Name  five  cities  in  the  United  States. 

How  far  is  this  from  New  York?  (or  from  the  nearest  town?) 

How  much  does  it  cost  to  go? 

A  health  officer  can  carry  on  the  following  activities  in  rela- 
tion to  the  feeble-minded: 

1.  Examining  suspected  cases,  especially  those  under  arrest, 
and  inmates  of  institutions  for  dependent  and  delinquent  persons. 

2.  Promoting  special  classes  for  those  retarded  in  school,  and 
especially  forming  manual  training  classes. 

3.  Securing  the  emploNTiient  of  feeble-minded  adults  where 
they  will  be  protected  from  temptation  and  from  those  who 
w^ould  take  advantage  of  their  condition. 

4.  Securing  proper  institutional  care  for  the  more  serious 
cases,  and  promoting  the  establishment  of  more  institutions  for 
them. 

5.  Promoting  measures  for  the  prevention  of  marriage  and 
procreation  among  the  feeble-minded,  wdth  special  consideration 
of  measures  for  securing  sterility  without  producing  other  evi- 
dent eft'ects. 


CHAPTER  XXXI 


VERMIN 


Disease-carrying  Vermin. — It  was  an  old  observation  that 
certain  diseases  were  associated  with  filth,  some  with  the  night 
air  of  swamps  and  marshes,  and  others  with  particular  places. 
The  mysterious  prevalence  of  many  of  these  diseases  has  been 
explained  by  the  discovery  and  demonstration  that  they  are 
transmitted  by  insects  and  other  vermin.  The  principal  ver- 
min with  which  a  health  officer  has  to  deal  are  flies,  mosquitoes, 
lice,  bedbugs,  ticks,  fleas,  and  rats.  A  number  of  tropical  dis- 
eases which  are  rarely  seen  in  temperate  zones  are  spread  by 
means  of  insects  which  are  found  only  in  hot  climates. 

FLIES 

Flies  transmit  diseases  either  by  biting  or  by  merely  acting 
as  the  agents  for  carrying  germs  which  accidentally  adhere  to 
their  bodies.  No  biting  fly  of  the  woods  and  fields  of  the  United 
States  is  known  to  transmit  any  disease.  The  common  stable 
fly  was  formerly  supposed  to  transmit  poliomyelitis  by  its  bite, 
but  that  theory  has  been  abandoned. 

The  two  flies  which  constitute  health  problems  in  the  United 
States  are  the  house-fly  and  the  blow-fly.  Both  are  exceedingly 
common  during  the  warm  months,  and  yet  their  breeding  could 
readily  be  controlled,  and  they  could  be  exterminated  by  the 
co-operative  efforts  of  every  person  in  a  community.  They  are 
often  the  means  of  spreading  typhoid  fever,  dysentery,  summer 
diarrhea,  and  other  infectious  diseases. 

Source  of  Disease  Germs. — Flies  transmit  diseases  because 
of  their  habits  of  feeding  on  wet  filth.  If  all  the  excretions  from 
human  beings  were  screened  or  covered  or  destroyed,  flies  could 
neither  obtain  disease  germs  nor  transmit  diseases.  Some  of 
the  germs  adhere  to  the  outside  of  the  bodies  of  the  insects,  and 
some  are  swallowed,  escape  digestion,  and  are  excreted  in  a 
living  state.  A  fly  is  a  shaggy  creature.  Although  it  appears 
to  be  shiny  and  glistening,  its  body  is  covered  with  hairs  and 
bristles  which  entangle  great  quantities  of  dust,  dirt,  and  bac- 
teria. It  tries  to  keep  itself  clean  by  rubbing  its  feet  together 
and  over  its  face  and  wings,  but  the  coarseness  and  abundance 
of  the  hairs  make  the  task  impossible.  When  a  fly  is  magnified 
under  a  microscope,  it  appears  like  a  bristly  monster  which  has 

327 


328 


THE  HEALTH   OFFICER 


been  wallowing  in  the  dust.  If  the  magnification  is  sufficiently 
great,  the  bacteria  on  the  bristles  look  like  grains  of  sand  on  the 
horns  of  a  great  beast. 

Every  fiy  is  co\ercd  with  bacteria  whose  numbers  depend 
largely  on,  their  abundance  in  the  filth  on  which  it  alights.  A 
method  of  estimating  their  number  is  to  shake  the  fly  in  a 
bottle  of  sterile  water  and  plate  the  water  as  in  the  bacterio- 
logic  examination  of  milk.  From  300.000  to  3.000,000  bacteria 
may  usually  be  obtained  from  the  outside  of  its  body,  and  as 


¥\".  29. — House-flies  on  a  collection  of  filth. 


many  more  from  its  digestive  tract.  The  bacteria  are  those  of 
the  substance  on  which  the  insect  alights.  Flies  nearly  always 
harbor  great  numbers  of  colon  bacilli  which  they  obtain  from  the 
excretions  of  human  beings  and  animals.  If  the  excretions  con- 
tain disease  germs,  the  flies  which  alight  on  them  will  carry  the 
germs  on  their  bodies  and  in  their  intestines. 

Inoculation  by  Flies. — A  fly  does  not  bite  or  pierce  the  skin, 
and  cannot  inject  germs  or  poisons  into  the  skin.  Its  mouth 
consists  of  a  flexible  tube,  like  an  elephant's  trunk,  ending  in  a 
flat  disk  with  which  it  takes  its  food  by  suction.     It  can  feed 


VERMIN  329 

only  on  liquid  matter.  When  it  tries  to  eat  a  dry  substance,  it 
dissolves  the  food  with  tiny  drops  of  liquid  which  it  regurgitates 
from  its  stomach.  A  fly  pours  filth  and  bacteria  from  its  last 
meal  upon  our  food,  our  skin,  our  mouths,  and  our  eyes.  It 
pollutes  them  with  its  intestinal  excretions,  and  sprinkles  them 
with  the  filth  which  it  rubs  from  the  bristles  on  its  body.  It 
leaves  a  trail  of  bacteria  on  every  substance  over  which  it  crawls. 
It  spreads  disease  germs  wherever  it  goes,  and  well  deserves  the 
name — deadly  typhoid  fly. 

Life-history. — House-flies  breed  in  manure  and  most  other 
kinds  of  decaying  matter.  Their  preference  is  stable  manure, 
but  they  will  breed  in  pig-pens,  garbage  heaps,  hen-roosts, 
privies,  and  rotting  vegetable  matter.     Blow-flies  breed  in  pu- 


Fig.  30. — A  house-fly,  showing  the  hairs  on  its  body. 

trefying  flesh.  Every  fly  passes  through  the  three  stages  of  egg, 
larva,  and  pupa  before  it  becomes  a  winged  creature. 

A  fly  is  hatched  from  a  white  or  yellow  egg  which  is  laid  by 
an  adult  fly.  A  female  usually  lays  two  or  three  hundred  eggs 
in  bunches,  called  fly  blows.  The  blows  on  meat  are  usually 
the  eggs  of  blue-bottle  flies,  but  house-flies  often  lay  their  eggs 
in  masses  on  meat  and  fish. 

Fly  blows  hatch  into  wormlike  larvae  called  maggots.  Every 
maggot  is  a  young  fly.  It  grows  rapidly,  moults  its  skin  several 
times,  and  completes  its  growth  in  about  a  week.  When  it 
reaches  a  length  of  about  f  inch,  its  skin  hardens,  and  it  becomes 
a  brown,  motionless  object  which  looks  like  a  large,  fat  grain  of 
wheat.     This  is  the  pupal  form,  and  while  it  remains  in  this 


330  THE   HEALTH   OFFICER 

stage,  its  wings  and  legs  grow,  and  it  develops  into  a  full-grown 
fly.  Every  fly  emerges  from  its  pupal  case  fully  grown.  Small 
flies  are  not  young  flies  that  are  growing  into  big  ones,  but  they 
belong  to  other  species  than  house-flies  or  blow-flies.  The  com- 
plete cycle  from  the  egg  to  the  full-grown  fly  usually  requires 
from  ten  to  fourteen  days. 

Maggots  about  to  change  to  pupa?  will  burrow  into  the  soil 
if  they  can  reach  it.  IMany  maggots  and  pup^e  may  usually 
be  found  in  the  ground  on  the  edge  of  a  manure  pile,  even  when 
the  soil  is  compact  and  hard. 

Most  flies  are  killed  by  the  frosts  of  autumn,  but  a  few  fe- 
males pass  the  winter  in  a  dormant  state  in  attics,  behind  chim- 


>.    - . 
Fig.  31.— House-fly's  foot  (XlOO). 

neys,  and  in  other  protected  places,  and  become  the  ancestors 
of  the  next  summer's  fly  crop.  A  fly  caught  in  winter  is  usually 
distended  with  eggs.  A  few  larvae  and  pupae  may  survive  the 
winter  in  protected  heaps  of  garbage  and  manure. 

Bacteria  which  a  maggot  eats  may  remain  alive  in  the  winged 
fly,  although  their  numbers  are  reduced  owing  to  the  phagocytosis 
which  takes  place  during  the  pupal  transformation.  A  fly  that 
is  hatched  in  human  excretions  may  still  carry  the  bacteria  of 
diseases  after  it  reaches  the  adult  stage. 

Extent  of  Danger. — Flies  were  formerly  responsible  for  a 
large  proportion  of  the  cases  of  epidemic  t}'phoid  and  para- 
t\-phoid  fevers  and  dysentery  in  soldiers'  camps  owing  to  the 


VERMIN 


331 


disposal  of  human  excretions  in  uncovered  and  un[)r(jtc(:tcfl 
trenches,  and  to  the  breeding  of  flies  in  horse  manure  and  gar- 
bage. There  is  danger  of  the  spread  of  intestinal  diseases  when- 
ever the  excretions  from  a  case  of  infectious  intestinal  disease 
are  emptied  into  a  privy  to  which  flies  have  access.  A  large 
proportion  of  the  diarrheas  of  infants  and  children  is  caused  by 
house-flies  which  carry  the  intestinal  discharges  from  a  sick  child 
to  the  food  or  mouths  of  other  children.  A  great  part  of  the 
unhealthfulness  of  hot  weather  is  due  to  the  flies  which  are 
prevalent  during  summer. 


n 


Fig.  32. — A  fly's  leg,  showing  the  coarse  hairs  with  which  it  is  covered  (X50). 


When  flies  have  been  marked  or  colored  for  identification  and 
released,  they  have  been  captured  in  traps  two  miles  from  the 
point  at  which  they  were  set  free.  A  breeding-place  will  supply 
flies  to  an  area  at  least  4  miles  in  diameter. 

Control  of  Fly-borne  Diseases. — The  control  of  fly-borne 
diseases  consists  (1)  in  guarding  the  sources  of  fly  infection,  and 
(2)  in  measures  for  the  exclusion  and  destruction  of  flies  them- 
selves. 

The  sources  from  which  flies  get  the  germs  of  infectious  dis- 
eases on  their  bodies  are  human  excretions  and  persons  who  are 
afflicted  wdth  infectious  diseases.  No  fly  could  pick  up  infectious 
matter  if  all  human  excretions,  sewage,  and  garbage  w^ere  cov- 


332 


THE  HEALTH    OFFICER 


ered  fly-tight,  and  the  insects  were  not  permitted  to  come  near 
a  person  who  has  an  infectious  disease.  It  is  the  duty  of  every 
health  ofticer  to  insist  on  fly-tight  privies  and  the  exclusion  of 
flies  from  sick  rooms. 

Antifly  Measures  in  Houses. — Every  fly  may  justly  be  con- 
sidered to  be  a  dangerous  pest  whose  presence  in  a  house  is  a 
menace  to  the  health  of  the  inmates.  Screens  to  exclude  flies, 
and  brushes  to  drive  out  the  few  which  gain  entrance,  are  neces- 
sary articles  of  the  sanitary  equipment  of  a  home.  Other  use- 
ful articles  of  quipment  are  fly  swatters,  traps,  sticky  paper,-  and 
poison  paper. 


Fig.  33.— House-fly's  mouth  (XlOO). 

A  1  per  cent,  solution  of  formaldehyd  or  of  salicylate  of  soda 
is  deadly  to  flies  that  drink  it.  A  fly  requires  an  abundance  of 
water.  If  a  room  is  closed  for  a  few  hours  and  darkened  except 
one  window  in  which  a  saucer  of  the  solution  is  placed,  the  flies 
will  go  to  the  window  and,  becoming  thirsty,  will  be  likely  to 
drink  their  poison.  The  solutions  are  useless  in  an  ordinary 
kitchen  or  dining-room,  for  the  flies  will  be  able  to  get  water 
elsewhere. 

Pyrethrum  powder  blown  through  the  air  of  a  room,  or  the 
smoke  of  the  burning  powder,  is  stupefying  to  flies  for  a  short 
time,  but  seldom  kills  them.  If  pyrethrum  is  used,  the  flies 
which  fall  to  the  floor  must  be  swept  up  and  killed. 


VERMIN 


333 


A  crude,  old-fashioned  method  of  catching  flies  is  to  tie  twigs 
of  bayberry  or  sweet  fern  in  bunches  about  the  size  of  one's 
head,  and  suspend  them  in  the  top  of  a  room  or  tent.  The  flies 
will  ahght  on  them  at  night  and  may  be  caught  in  a  pillow-case 
or  bag  slipped  over  the  bunches. 

Fly-traps. — Practical  outdoor  measures  for  the  extermina- 
tion of  the  fly  pest  are  trapping  and  the  control  of  their  breeding- 
places.  White  houses  on  sunny  hillsides  in  sections  of  a  city  or 
village  remote  from  fly  breeding-places  are  sometimes  afiflicted 
with  plagues  of  flies.  About  the  only  practical  means  of  reduc- 
ing the  number  of  flies  after  they  have  developed  is  to  catch 
them  in  traps.  An  efficient  fly-trap  is  a  box  made  of  wire  net- 
ting 2  feet  square.     Its  bottom  is  a  cone  inverted  over  bait. 


Fig.  34. — Photomicrograph  of  the  edge  of  a'  fly's  wing  laid  upon  a  pure  culture  of 
diphtheria  germs  (X  500). 

The  flies  eat  the  bait  and  walk  up  the  cone  through  a.  small 
opening  in  the  top  and  into  the  upper  part  of  the  trap.  Flies 
are  attracted  to  the  bait  by  its  odor.  A  saucer  of  vinegar  or 
stale  beer  mixed  with  molasses  or  moist  sugar  makes  an  excel- 
lent bait.  The  number  of  flies  caught  may  be  estimated  on  the 
basis  of  13,000  flies  to  each  quart. 

Control  of  Breeding-places. — The  most  effective  measure  for 
exterminating  flies  is  the  control  of  manure  piles,  pig-pens,  dead 
animals,  and  other  decaying  matter  in  which  flies  breed.  Flies 
prefer  to  lay  their  eggs  in  fresh,  damp  manure.  If  the  manure 
is  carted  away  frequently  and  spread  upon  the  land,  it  will  dry 
and  maggots  cannot  mature  in  it.  The  removal  must  be  done 
at  least  once  a  week,  and  during  hot  weather,  when  the  maggots 


334  THE   HEALTH   OFFICER 

grow  rapidly,  twice  a  week.  If  manure  is  removed  from  the 
vicinity  of  houses,  and  is  piled  in  a  firm,  compact  heap,  few 
tlies  will  breed  in  it,  especially  if  the  outside  is  kept  dry.  When 
only  a  small  quantity  of  manure  is  produced,  it  may  be  stored 
in  cement  bins  which  are  covered  to  exclude  flies.  This  method 
of  storing  manure  is  required  by  the  ordinances  of  some  villages 
and  cities. 

Borax  in  the  proportions  of  1  pound  to  each  8  bushels  of 
stable  manure  is  efficient  in  preventing  flies  from  breeding. 
When  the  manure  is  snugly  piled,  sift  the  powder  over  the 
heap  and  sprinkle  it  with  water  in  order  to  dissolve  the  chemical 
and  carry  it  through  the  mass.  Powdered  hellebore  is  also 
etlicient  used  in  the  same  quantities  as  borax. 

Pig-pens  and  cow-yards  present  the  greatest  difficulty  in  the 
prevention  of  fly  breeding,  for  their  edges,  which  the  animals 
cannot  reach,  usually  contain  maggots  and  pupa;  aU  through  the 
summer.  Cleanliness  and  dryness  are  essential  in  preventing 
fly  breeding  in  the  pens. 

Education.^A  rural  health  officer  will  often  have  difficulty 
in  deciding  how  much  antifly  work  he  can  do,  especially  among 
farmers  and  liverymen.  His  first  step  must  be  to  educate  those 
who  maintain  fly  breeding-places.  It  is  surprising  how  few 
persons  know  what  maggots  and  fly  pupas  are.  An  effective 
means  of  educating  a  doubting  farmer  is  to  place  a  few  maggots 
and  pupa;  in  a  covered  jar  or  tin  can  with  a  httle  manure,  and 
let  him  see  what  comes  from  them.  Another  means  of  education 
is  to  cut  open  a  pupa  case  with  care  and  show  the  farmer  the 
young  fly  in  it.  When  farmers  and  their  wives  and  children 
understand  how  and  where  flies  breed,  they  will  show  a  greater 
willingness  to  co-operate  in  antifly  work. 

MOSQUITOES 

Mosquitoes  are  always  nuisances,  and  sometimes  they  con- 
stitute a  serious  menace  to  health.  Certain  kinds  are  the  only 
known  means  by  which  malaria  and  yellow  fever  are  spread. 
The  saliva  which  a  mosquito  injects  when  it  sucks  blood  causes 
an  itching  papule  on  the  skin  of  a  susceptible  person.  The  health 
officer  may  properly  be  a  leader  in  antimosquito  work;  and 
wherever  malaria  or  yellow  fever  exists,  it  is  his  duty  to  promote 
the  work  of  exterminating  the  pests  by  every  means  in  his 
power.  Adult  mosquitoes  live  mostly  on  plant  juices.  Only 
the  females  suck  blood,  and  probably  only  a  few  of  them  have 
the  opportunity  to  obtain  that  food. 

jVIosquitoes  cling  to  grass  and  bushes  where  they  are  pro- 


VERMIN  335 

tected  from  winds.     Shrubbery  and  tall  grass  around  houses  do 
not  breed  mosquitoes,  but  only  afford  hiding  places  for  them. 

Life-history. — Mosquitoes  breed  in  still  water,  especially 
that  which  is  stagnant  and  contains  an  abundance  of  food. 
They  pass  through  the  stages  of  egg,  larva,  and  pupa  before 
they  reach  the  adult  form.  The  life-histories  of  the  different 
species  vary  in  their  details,  but  that  of  the  common  rain-barrel 
mosquito  is  typical  of  all  the  rest.  The  eggs  of  this  species  are 
laid  in  neat  bunches  which  float  on  the  surface,  and  look  like 
flakes  of  soot.  The  larvae  which  hatch  are  called  wigglers,  from 
their  habit  of  wiggling  through  the  water  with  quick,  jerking 


^ 


\ 


Fig.  35. — Adult  mosquito  emerging  after  completing  the  under-water  stage  of  its 

life. 

movements.  They  breathe  through  tubes  located  in  the  hinder 
ends  of  their  bodies,  and  when  quiet  they  hang  with  their  heads 
downward  and  with  the  end  of  their  breathing  tubes  at  the  sur- 
face of  the  water  in  order  to  obtain  air.  They  change  to  pupae 
in  about  a  week  if  the  weather  is  warm,  and  then  appear  as 
humpbacked  creatures  which  still  have  the  power  of  moving 
quickly.  After  two  or  three  more  days  the  skins  of  the  pupae 
split  open  and  the  winged  mosquitoes  emerge  at  the  surface  of 
the  water  and  fly  away. 

Anopheles  Mosquitoes. — Over  fifty  species  of  mosquitoes 
breed  in  New  York  State,  and  probably  a  hundred  in  the  United 
States.     Those   which   produce   malaria   belong   to   the  genus 


336  THE  HEALTH   OFFICER 

Anopheles.  The  two  most  common  species  are  the  quadrimacu- 
latits,  which  has  four  black  spots  on  each  wing,  and  the  puncti- 
peniiis,  whose  wing  has  a  yellow  spot.  The  usual  breeding- 
places  of  the  Anopheles  are  natural  upland  pools  in  woods, 
marshes,  and  swamps.  They  do  not  breed  in  salt  marshes  or 
in  water  so  foul  that  it  is  offensive.  Their  larva'  may  be  recog- 
nized by  their  resting  position,  which  is  at  the  surface  of  the 
water  and  parallel  with  it.  The  adult  Anopheles  may  be  recog- 
nized by  its  body  pointing  away  from  the  surface  on  which  it 
alights.  The  Anopheles  mosquitoes  are  not  strong  fliers,  but 
they  may  be  carried  2  or  3  miles  by  the  wind.  They  do  not 
fly  or  bite  by  day,  but  are  active  in  the  forepart  of  the  evening. 
A  person  who  stays  indoors  during  the  first  part  of  the  night 
behind  screens  which  the  mosquitoes  cannot  pass  will  not  be- 
come infected  with  malaria.  The  peculiar  hours  kept  by  the 
Anopheles  mosquitoes  gave  rise  to  the  belief  that  the  night  air 
during  the  evening  was  full  of  miasma  which  disappeared  before 
dawn. 

Aedes  Calopus. — The  yellow  fever  mosquito  belongs  to  the 
genus  Aedes,  which  was  formerly  called  Stegomyia.  It  is  active 
only  by  day  and  around  lights  at  night.  It  breeds  in  small 
artificial  collections  of  water  in  the  vicinity  of  houses,  such  as 
cisterns,  water-tanks,  and  rain-barrels.  It  is  a  domestic  insect, 
and  seldom  goes  more  than  a  few  hundred  feet  from  human 
habitations.  The  work  of  exterminating  it  in  its  breeding- 
places  does  not  need  to  be  carried  on  more  than  a  quarter  of  a 
mile  from  a  village  or  dwelling-house. 

Culex  Mosquitoes. — The  ordinary  mosquitoes  belong  to  the 
genus  Citlex,  and  are  harmless  except  for  the  great  annoyance 
of  their  bites.  There  are  numerous  species  which  may  roughly 
be  divided  into  three  groups,  the  domestic,  the  fresh-water  or 
swamp,  and  the  salt  marsh  mosquitoes.  The  domestic  species 
breed  in  rain-barrels,  water-buckets,  cesspools,  and  other  collec- 
tions of  stagnant  water  in  the  vicinity  of  houses  and  barnyards. 
No  water  is  too  foul  for  them,  and  their  most  prolific  breeding- 
places  are  uncovered  cesspools  and  barrels  of  liquid  manure. 
They  do  not  fly  far,  and  the  destruction  of  a  single  breeding- 
place  near  a  house  will  usually  be  followed  by  a  great  reduction 
in  the  number  of  mosquitoes  at  that  place. 

The  wild,  fresh-water  species  breed  in  swamps,  marshes,  and 
pools.  The  first  broods  appear  early  in  spring,  and  are  hatched 
from  eggs  that  are  laid  in  the  mud  in  the  fall.  Roadside  mud 
puddles  in  the  early  spring  are  often  swarming  with  their  larvas. 
They  usually  appear  in  distinct  broods  which  hatch  after  a  hard 
rainfall  has  flooded  the  eggs  which  were  laid  at  the  edges  of  the 


VERMIN  337 

pools  while  the  water  was  low.  These  mosquitoes  are  travel- 
ers, and  those  from  a  swamp  may  infest  a  neighborhood  for 
several  miles  around. 

The  salt  marsh  mosquito  breeds  only  in  the  water  of  salt 
marshes  along  the  seacoast.  The  common  kind  may  be  recog- 
nized by  the  broad  transverse  stripes  of  white  upon  its  legs. 
It  is  a  great  traveler,  and  is  sometimes  found  in  swarms  at  sea 
out  of  sight  of  land,  and  for  20  miles  inland.  A  large  propor- 
tion of  the  mosquitoes  within  20  miles  of  the  seacoast  are  bred 
in  salt  marshes.  Their  breeding  habits  are  similar  to  those  of 
the  swamp  varieties. 

Control  of  Mosquitoes. — The  control  of  the  yellow  fever 
mosquito  is  universally  recognized  as  a  grave  public  health 
problem.  The  control  of  the  malarial  mosquito  is  usually  as- 
sumed by  boards  of  health  in  only  the  richer  and  more  thickly 
settled  municipalities.  The  extermination  of  the  culex  species 
has  usually  been  considered  principally  as  an  economic  prob- 
lem affecting  real  estate  values.  But  there  is  a  growing  senti- 
ment in  favor  of  general  antimosquito  work,  and  the  demonstra- 
tion of  its  success  at  a  comparatively  small  cost  in  the  vicinity 
of  New  York  City  is  awakening  boards  of  health  and  civic 
societies  to  the  importance  and  practicability  of  the  work.  It 
is  the  duty  of  every  health  officer  to  become  familiar  with  the 
methods  of  mosquito  prevention.  If  the  culex  mosquitoes  are 
controlled,  the  disease-bearing  species  will  be  included  in  the 
extermination.  The  control  of  mosquitoes  and  mosquito-borne 
diseases  will  include  the  following  measures: 

1.  Screening  houses  against  mosquitoes,  especially  those 
houses  which  are  occupied  by  persons  who  have  malaria  or  yel- 
low fever. 

2.  Emptying  or  covering  all  places  for  the  collection  of  stand- 
ing water,  such  as  rain-barrels,  cisterns,  cesspools,  gutters,  tin 
cans,  hollow  trees,  stumps,  and  flower  vases. 

3.  Filling,  draining,  or  ditching  pools,  swamps,  and  marshes. 

4.  Covering  ponds,  pools,  and  small  collections  of  water 
with  a  thin  film  of  oil  which  prevents  the  larv£e  from  breath- 
ing. 

5.  Stocking  pools,  fountains,  and  reservoirs  with  gold  fish — 
a  hardy  specie  of  carp — which  eat  the  larvae. 

The  control  of  mosquitoes  is  always  a  community  problem, 
and  its  success  requires  the  co-operation  of  every  householder 
and  land-owner.  The  laws  of  New  Jersey  and  New  York 
authorize  counties  to  do  the  work.  It  is  essential  that  it  be  done 
under  the  direction  of  an  expert  who  will  make  a  complete  sur- 
vey of  the  whole  territory,  locate  the  breeding-places,  identify 


338  THE   HEALTH   OFFICER 

the  species  of  mosquitoes  that  are  found,  and  co-ordinate  and 
supervise  all  phases  of  the  preventi\e  and  corrective  measures. 
The  antimosquito  work  of  a  health  otlicer  is  principally 
educational.  Most  people  do  not  know  what  young  mosquitoes 
are  and  where  they  breed.  The  health  officer  can  give  talks  to 
school  children,  and  supply  them  with  bottles  of  wigglers.  The 
demonstration  of  their  transformation  into  winged  mosquitoes  is 
an  effective  means  of  arousing  interest  in  the  mosquito  problem. 
The  health  officer  will  also  find  real  estate  dealers  and  civic 
societies  among  his  assistants  in  mosquito  extermination. 

LICE 

Three  kinds  of  lice  may  infect  the  human  body:  1,  the  head 
louse,  Pediculus  capitis,  in  the  hair  of  the  head;  2,  the  body 
louse,  Pediculus  corporis,  in  the  underclothes;  and  3,  the  Pedic- 
ulus pubis,  on  the  covered  hairy  parts  of  the  body. 

The  louse  is  a  biting  insect.  It  produces  an  intense  itching 
of  the  skin,  and  its  presence  may  be  suspected  when  scratch- 
marks  are  found  on  the  skin.  City  hospitals  sometimes  admit 
serious  cases  of  illness  due  to  sores  caused  b}^  scratching  on 
account  of  lice.  But  lice  are  important  to  the  health  officer 
principally  because  they  are  the  only  know^n  carriers  of  typhus 
fever.  Both  head  hce  and  body  lice  may  transmit  the  disease 
by  sucking  up  the  germs  with  the  blood  of  an  infected  person 
and  transmitting  them  to  other  persons  whom  they  bite.  It 
was  supposed  that  typhus  fever  was  almost  completely  eradi- 
cated from  the  United  States,  but  a  mild  form,  called  Brill's 
disease,  is  frequently  seen.  T^-phus  is  endemic  in  ISIexico,  and 
in  the  Balkan  States,  and  Asia  Minor,  and  its  control  has  been 
an  exceedingly  grave  problem  in  the  European  War.  The  meth- 
ods for  its  suppression  are  directed  against  lice.  Epidemics  of 
the  disease  may  appear  in  the  United  States,  as  they  formerly 
did,  unless  health  authorities  are  vigilant  in  the  extermination 
of  lice. 

Life-history. — Lice  hatch  from  white  eggs  called  iiils.  Those 
of  the  body  louse  are  attached  to  the  underclothing,  especially 
the  seams  about  the  shoulder.  Those  of  other  species  are  at- 
tached to  hairs  near  the  roots,  and  as  the  hairs  grow,  the  eggs 
are  carried  aw-ay  from  the  body.  The  time  during  which  the 
lice  have  infested  the  body  may  be  estimated  by  the  length  of 
the  hair  between  the  eggs  and  the  skin.  The  eggs  usually  hatch 
in  about  two  weeks,  and  the  empty  egg  cases  are  left  attached 
to  the  hairs  or  clothes.  The  young  resemble  the  adults,  and 
there  is  no  transformation  such  as  occurs  among  the  young  of 
flies  and  mosquitoes. 


VERMIN  339 

Head  lice  are  common  among  school  children  over  the  whole 
United  States,  and  from  5  to  10  per  cent,  are  found  harboring 
them  wherever  careful  examinations  are  made.  The  lice  are 
spread  principally  by  means  of  hats.  The  control  of  infected 
children  is  within  the  scope  of  the  duties  of  a  health  officer,  and 
it  is  proper  for  him  to  exclude  those  children  on  whom  either 
lice  or  nits  are  found. 

The  extermination  of  head  lice  requires  thorough  measures. 
A  harmless  and  efficient  method  is  to  saturate  the  hair  with  equal 
parts  of  olive  oil  and  kerosene,  bind  it  up  with  a  thick  towel, 
and  leave  it  on  all  night.  This  will  kill  the  adults  and  most  of 
the  nits.  Wash  the  head  with  soapsuds  in  the  morning.  Then 
wet  the  hair  with  vinegar  in  order  to  dissolve  the  glue  which 
binds  the  eggs  to  the  hair,  and  comb  out  the  loosened  nits.  If 
the  vinegar  and  combing  are  omitted,  some  of  the  unhatched 
eggs  may  escape  destruction  and  bring  forth  a  new  crop  of  lice. 

If  a  school  child  has  lice,  its  brothers,  sisters,  and  parents 
usually  have  them  also.  Home  visitations  and  the  treatment 
of  whole  families  is  necessary  in  exterminating  lice  from  a  school. 
The  work  is  done  successfully  only  in  those  communities  which 
employ  a  public  health  nurse. 

Body  Lice. — The  control  of  body  lice  is  a  troublesome  prob- 
lem owing  largely  to  the  difficulty  in  discovering  the  cases,  and 
of  reaching  all  the  clothes  of  the  affected  person.  The  Hce  sel- 
dom remain  on  the  body,  but  are  found  on  the  clothing.  Boil- 
ing or  baking,  or  subjecting  the  clothes  to  steam  under  pressure 
will  kill  both  the  lice  and  their  nits.  Soaking  the  clothing  in  a 
1  :  500  solution  of  bichlorid  of  mercury  is  also  effective.  Those 
who  handle  the  affected  persons  and  their  clothing  are  likely  to 
take  the  hce  unless  they  use  great  care  to  guard  against  them. 

Pubic  lice  may  be  destroyed  by  the  application  of  mercurial 
ointment  or  a  1  :  500  solution  of  bichlorid.  Either  one  is  to  be 
washed  off  with  soap  and  water  after  about  ten  minutes. 

BEDBUGS 

Bedbugs  (Cimex  lectularius)  are  biting  insects.  The  germs 
of  tuberculosis  have  been  found  in  their  bodies,  and  they  may 
harbor  other  disease  germs.  The  insects  are  widely  distributed 
and  it  is  probable  that  some  have  been  introduced  into  every 
household  at  some  time.  One  may  be  recognized  by  its  oft"ensive 
odor.  When  a  house  becomes  infested  with  them,  they  crawl 
into  cracks  and  behind  loosened  wall-paper,  where  they  may  live 
for  weeks  or  months  without  food.  Their  eggs  are  laid  in  the 
cracks  and  crevices  in  which  the  insects  hide. 

The  measures  for  the  extermination  of  bedbugs  are  a  thor- 


340  THE   HEALTH   OFFICER 

ough  housecleaning,  the  removal  of  all  loose  wall-paper,  boiling 
the  bedclothing.  and  soaking  the  joints  of  the  bed  and  cracks 
in  the  floor  with  gasolene,  or  kerosene,  or  a  strong  bichlorid 
solution. 

TICKS 

Ticks  are  eight-legged,  blood-sucking  creatures  which  are 
related  to  the  spiders.  An  empty  tick  is  about  I  inch  in  diameter 
and  resembles  a  bedbug;  but  when  it  feeds,  it  distends  itself 
with  blood  until  it  is  h  inch  or  more  in  diameter.  It  attaches 
itself  to  the  skin  so  lirmly  that  its  head  often  breaks  oflf  when 
its  body  is  pulled  in  attempts  to  remove  it.  A  common  species 
of  tick  is  found  in  the  woods  and  often  infests  dogs  and  persons. 
Ticks  are  hatched  from  eggs  which  are  laid  in  masses  on  the 
ground.  The  young  attach  themselves  to  small  animals,  such 
as  mice,  ground  squirrels,  and  other  rodents,  and  live  by  sucking 
their  blood.  They  fall  ofT,  undergo  a  transformation,  and  reat- 
tach themselves  to  an  animal.  They  repeat  the  process  and 
finally  reach  their  adult  form. 

Ticks  are  important  to  the  health  officer  because  they  may 
transmit  diseases.  One  species  (Margaropus  annulatus)  trans- 
mits Texas  fever  to  cattle.  Another  tick  (Dermacentor  venus- 
tus)  is  the  cause  of  Rocky  Mountain  fever.  This  is  a  disease 
resembling  t\phus  fever.  The  tick  which  causes  it  is  found  on 
numerous  species  of  wild  animals,  but  chiefly  on  domestic 
animals.  The  control  of  the  disease  consists  in  measures  for 
the  extermination  of  ticks  on  horses  and  cattle,  such  as  dips, 
sprays,  and  washes  containing  arsenic  or  other  poisonous  sub- 
stance. 

Relapsing  fever  is  sometimes  caused  by  a  tick,  but  it  may  also 
be  transmitted  by  other  biting  insects. 

FLEAS 

Fleas  are  blood-sucking  insects.  They  are  of  importance  to 
the  health  ofiticer  chiefly  because  those  of  certain  species  may 
transmit  the  plague,  provided  they  bite  a  person  or  animal  that 
has  the  disease.  The  species  which  are  specially  implicated  with 
the  plague  in  the  United  States  are  the  rat  flea  (Ceratophyllus 
fasciatus)  and  the  squirrel  flea  (Ceratophyllus  acutus).  One 
species  (Pulex  irritans)  infests  human  beings,  but  it  is  rare  in 
the  United  States  and  is  usually  harmless.  The  common  Ameri- 
can flea  that  bites  persons  is  the  dog  or  cat  flea  (Pulex  serraticeps), 
but  it  usually  attacks  only  certain  persons  and  avoids  others. 
A  flea  that  is  peculiar  to  one  specie  of  animal  may  bite  another 
species  if  it  cannot  feed  upon  the  one  which  it  prefers,  and  this 


VERMIN  341 

peculiarity  accounts  for  the  transmission  of  the  plague  by  fleas 
from  infected  rats  and  squirrels. 

A  flea  is  hatched  from  eggs  which  are  usually  laid  among 
the  hairs  of  the  animal  on  which  it  lives.  They,  or  the  newly 
hatched  young,  fall  upon  the  ground  or  on  carpets  and  floors. 
The  young  are  wormlike  larvae  which  live  upon  vegetable  matter 
or  house  dust.  They  spin  cocoons  in  which  they  pass  the  pupal 
stage,  and  finally  emerge  as  fully  developed  fleas  which  return 
to  an  animal  at  the  first  opportunity. 

Fleas  sometimes  become  abundant  in  houses.  These  are 
probably  hatched  from  eggs  which  fall  from  infested  dogs  and 
cats.  It  is  almost  impossible  to  get  rid  of  them  without  remov- 
ing the  furniture  and  carpets  in  which  they  hide.  Scrubbing 
the  floors  with  an  emulsion  of  kerosene  and  soapsuds  will  kill 
many  of  them,  and  flake  naphthalene  sprinkled  on  the  floor  will 
usually  drive  away  the  rest. 

RATS 

Rats  are  of  importance  to  the  health  officer  because  they  may 
transmit  diseases,  especially  plague  and  trichinosis  (page  312). 
Plague  is  a  disease  of  rodents,  and  in  America  it  is  found  among 
the  rats  and  ground  squirrels  of  the  localities  where  it  has 
appeared.  An  animal  becomes  infected  by  contact  with  one 
which  has  the  open  lesions  of  the  disease,  by  eating  the  flesh 
of  those  which  have  died  of  plague,  and  by  the  bites  of  fleas 
from  the  sick.  The  infection  is  usually  carried  to  human  beings 
by  means  of  fleas  from  the  bodies  of  rats  that  have  died  from 
plague.  The  preventive  measures  against  plague  are  directed 
principally  against  rats. 

The  common  rats  of  America  are  burrowing  animals,  and 
their  underground  habits  and  their  intelligence  render  their 
extermination  difficult.  They  can  live  upon  almost  any  kind 
of  food  that  will  support  the  life  of  any  of  the  other  higher 
animals.  Their  activity,  strength,  and  gnawing  powers  enable 
them  to  penetrate  almost  every  storehouse  of  food  that  is  not 
specially  guarded.  They  are  pests  on  board  of  ships,  in  sewers, 
along  wharves,  and  in  heaps  of  garbage  and  rubbish.  Since 
they  are  not  at  all  particular  in  their  food,  they  can  live  and 
flourish  where  other  animals  would  starve.  Their  control  is 
possible  only  if  it  is  undertaken  as  a  community  problem,  as 
has  been  done  in  Manila,  San  Francisco,  and  other  places  in 
which  plague  has  appeared. 

The  means  for  the  control  of  rats  are : 

1.  Capturing  them  by  such  means  as  trapping  and  shooting, 
and  hunting  them  with  dogs,  cats,  and  ferrets.     Very  little  will 


342  THE   HEALTH    OFFICER 

be  accomplished  by  these  methods  unless  they  are  excluded 
from  their  usual  food  supplies,  and  most  of  their  holes  and  run- 
ways are  closed. 

2.  Poisoning  them  with  arsenic,  phosphorus,  strychnin,  ba- 
rium carbonate,  or  cyanid  of  potassium. 

3.  Bacterial  rat  \'iruses.  Those  on  the  market  belong  to  the 
paratyphoid  group  and  are  more  infective  for  domestic  animals 
than  for  rats.  They  are  not  successful  against  the  rat,  but  are 
dangerous  to  domestic  animals  and  to  man. 

4.  Clearing  away  rubbish  and  garbage  in  which  the  rats  hide 
and  breed,  and  repairing  floors  and  raising  them  above  the 
ground  in  order  that  cats  and  other  natural  enemies  may  have 
access  to  their  underground  retreats. 

5.  Rat-proofing  buildings.  Rats  will  not  usually  remain  in 
a  building  unless  they  can  burrow  beneath  it,  or  hide  in  holes 
and  cre\-ices,  or  in  heaps  of  rubbish.  Cement  underground 
construction,  and  tight,  raised  floors  mil  usually  exclude  rats, 
and  the  few  that  may  enter  will  soon  leave  or  die  if  they  cannot 
obtain  water  and  food. 

6.  Guarding  ships.  Plague  is  usually  carried  from  place  to 
place  by  means  of  rats  on  ships.  Elaborate  measures  are 
taken  for  the  control  of  rats  along  the  water  fronts  in  plague 
districts.  Ships  are  moored  a  few  feet  from  shore,  their  cables 
are  provided  A\dth  flanges  which  prevent  the  rats  from  crawling 
along  them;  the  gang-planks  are  kept  raised  when  not  in  use; 
and  the  holds  of  the  vessels  are  fumigated  with  cyanid  gas  in 
order  to  destroy  any  rats  that  may  have  passed  by  the  guards. 

FUMIGATION 

Insects,  rats,  and  other  vemiin  in  rooms,  the  holds  of  vessels, 
and  other  confined  spaces  may  be  killed  by  fumigation  with 
sulphur  dioxid  or  with  hydrocyanic  acid  gas.  Sulphur  dioxid, 
SO2,  is  formed  by  burning  powdered  sulphur.  From  2  to  5 
pounds  of  sulphur  are  required  for  each  1000  cubic  feet  of  air 
space,  and  the  room  or  compartment  must  be  tightly  closed 
and  kept  closed  for  three  or  four  hours.  The  method  of  using 
the  gas  is  as  follows: 

Place  the  sulphur  in  flat  iron  pots  which  are  set  in  shallow 
tubs  of  water.  j\Iake  an  excavation  in  the  center  of  the  sulphur, 
pour  in  an  ounce  of  alcohol,  and  set  it  on  fire.  The  heat  of  the 
combustion  will  melt  the  surrounding  sulphur  which  will  run 
down  and  feed  the  flame. 

An  objection  to  sulphur  is  that  it  corrodes  metals  and  rots 
cloth  with  which  it  comes  in  contact.  The  corrosive  action  is 
due  to  sulphurous  acid,  H2SO3,  which  is  formed  when  the  dioxid 


VERMIN  343 

unites  with  the  vapor  of  water.  The  action  may  be  prevented 
by  covering  the  metal  with  vaselin  or  other  oil,  and  by  having 
the  room  and  the  air  as  dry  as  possible.  The  presence  of 
moisture  is  not  necessary  in  killing  animal  life,  although  it  is 
in  destroying  the  life  of  bacteria.  The  advantages  of  sulphur 
fumigation  are  its  efficiency,  the  ease  with  which  sulphur  may 
be  obtained  and  burned,  and  its  safety  to  human  beings,  for  the 
odor  of  the  gas  gives  warning  of  its  presence  before  it  accumulates 
in  dangerous  amounts. 

Hydrocyanic  acid  gas  is  intensely  poisonous.  A  few  whiffs 
are  deadly  to  human  beings,  but  its  poisonous  quality  makes  it 
efficient  in  killing  vermin.  It  has  only  a  slight  odor,  and  it  may 
be  present  in  the  air  in  dangerous  amounts  without  its  smell 
betraying  its  presence.  When  it  has  been  used  in  a  room  or 
compartment,  provision  must  be  made  for  opening  the  windows 
or  other  ventilators  from  the  outside,  and  free  ventilation  must 
be  carried  on  for  some  hours  before  a  person  may  safely  enter. 
Hydrocyanic  acid  fumigation  is  not  safe  except  when  it  is  done 
by  a  careful,  experienced  operator,  but  the  method  is  easy  and 
efficient  when  it  is  done  by  an  expert.  It  is  frequently  used  for 
killing  insects  in  greenhouses,  for  it  is  harmless  to  plants. 

The  method  of  cyanid  fumigation  is  as  follows: 

Potassium  cyanid,  1.0    part; 

Sulphuric  acid,  1.5    parts; 

Water,  2.25  parts. 

Use  10  ounces  of  cyanid  to  each  1000  cubic  feet  of  space. 
Add  the  sulphuric  acid  to  the  water  in  a  glazed  earthen  jar. 
Add  the  cyanid  and  leave  the  room  at  once  and  without  breathing. 

The  method  used  on  shipboard  is  to  generate  the  gas  in  a 
tightly  closed  tank  from  which  a  pipe  conducts  the  gas  into  the 
vessel's  hold. 


CHAPTER  XXXII 

MILK 

There  is  a  direct  relation  between  a  milk-supply  and  the 
health  of  the  people  of  a  community.  Milk  may  contain  dis- 
ease germs  when  it  is  drawn  from. a  diseased  cow.  Disease 
germs  may  be  introduced  into  it  by  unhealthy  workmen  or  from 
unclean  containers;  and  the  ordinary  changes  which  milk  under- 
goes may  render  it  unwholesome.  The  supervision  of  milk- 
supplies  is  one  of  the  important  duties  of  a  health  officer. 

Composition. — Milk  contains  all  the  elements  of  a  complete 
food  in  about  the  following  proportions: 

Per  cent. 

Protein 3.6 

Fat 3.8 

Sugar 4.7 

Ash : 0.7 

Water _S7^ 

Total 100.0 

These  proportions  vary  in  different  animals,  and  in  the  same 
animal  at  different  times.  The  extreme  variations  in  appar- 
ently normal  milk  drawn  from  healthy  cows  is  about  as  follows: 

Per  cent.,  Per  cent., 

low.  high. 

Protein 2.1  8.5 

Fat 2.2  9.0 

Sugar 4.0  6.0 

Ash 0.6  0.9 

There  is  an  approximate  relation  between  the  percentage  of 
fat  and  that  of  the  other  constituents  of  milk.  When  the  fat 
content  is  high,  the  percentage  of  the  other  constituents  is  usu- 
ally high  also;  and  a  low  percentage  of  fat  is  usually  accompanied 
by  a  low  percentage  of  the  other  solids.  The  percentage  of  fat 
is,  therefore,  a  rehable  indication  of  the  value  of  a  sample  of 
milk. 

The  laws  of  the  various  states  fix  minimum  standards  for 
the  composition  of  milk  that  is  offered  for  sale.  The  New  York 
standard  is  that  milk  shall  contain  at  least  3  per  cent,  of  fat  and 
11|  per  cent,  of  total  solids  (Agricultural  Law,  Section  30). 

A  health  officer  must  consider  the  natural  variations  in  the 
composition  of  milk  in  judging  the  value  of  a  milk  analysis. 

344 


MILK 


345 


Strippings,  or  milk  drawn  from  a  nearly  empty  udder,  contains 
five  or  ten  times  as  much  fat  as  the  first  milk  drawn  from  a  full 
udder.  Milk  produced  by  cows  of  the  Jersey  breed  will  usually 
contain  from  30  to  50  per  cent,  more  fat  than  those  of  the 
Holstein  and  similar  breeds.  Evening  milk  contains  slightly 
more  fat  than  morning  milk,  and  that  produced  in  late  fall  and 
winter  is  richer  than  that  produced  during  the  summer. 

Adulteration. — A  lowering  of  the  percentage  of  fats  and  solids 
in  milk  is  caused  principally  by  the  removal  of  cream  or  the 
addition  of  water.  These  processes  constitute  two  forms  of 
adulteration  according  to  the  New  York  State  Agricultural 
Law,  Section  30.  Neither  process  affects  the  wholesomeness  of 
the  milk,  but  selling  adulterated  milk  or  offering  it  for  sale  as 
whole  milk  is  a  fraud.  The  Department  of  Agriculture  is  charged 
with  the  detection  of  adulterated  milk  in  New  York,  but  a 
health  officer  is  frequently  consulted  regarding  suspected  adul- 
terations. Three  tests  which  are  usually  made  in  detecting 
adulterations  of  milk  are:  1,  the  specific  gravity;  2,  the  Babcock 
test  for  fats;  and  3,  the  percentage  of  total  solids. 

Specific  Gravity. — Milk  that  has  been  skimmed  or  watered 
may  usually  be  detected  by  means  of  its  specific  gravity.  The 
specific  gravity  of  milk  that  is  above  the  minimum  standard  of 
composition  is  between  1.030  and  1.034.  Removing  the  cream 
increases  the  specific  gravity,  since  fat  is  lighter  than  whole 
milk.  Adding  water  lowers  the  specific  gravity,  since  it  reduces 
the  percentage  of  solids  which  are  dissolved  in  the  liquid  part  of 
milk.  If  the  specific  gravity  of  a  sample  of  milk  is  below  1.030 
or  above  1.034,  the  milk  may  be  considered  to  be  adulterated. 
It  is  possible  to  remove  the  cream  and  to  add  a  sufficient  quan- 
tity of  water  to  preserve  a  normal  specific  gravity,  but  a  sample 
of  such  milk  would  be  so  thin  and  blue  as  to  be  suspicious. 

The  specific  gravity  of  milk  is  usually  taken,  by  a  special 
form  of  hydrometer,  called  a  lactometer;  but  a  health  officer 
can  take  it  with  an  ordinary  urinometer.  The  standard  test  is 
made  at  a  temperature  of  60°  F.  If  it  is  made  at  another  tem- 
perature, a  correction  is  to  be  made  by  adding  0.0001  to  the  read- 
ing for  every  degree  below  60°  F.  For  example,  if  the  specific 
gravity  is  1.032  at  a  temperature  of  55°  F.,  the  corrected  reading 
would  be  1.0325. 

Test  for  Fat. — The  test  for  fat  is  nearly  always  made  by  the 
Babcock  method,  in  which  the  casein  is  destroyed  by  sulphuric 
acid  and  the  fat  is  liberated  and  collected  as  a  clear  oil.  The 
apparatus  required  is  a  graduated  pipet,  a  centrifuge,  and  a 
special  flask  with  a  neck  holding  2  c.c.  and  graduated  in  tenths 
and  hundredths  parts.     The  method  is  as  follows:  Mix  17.5  c.c. 


346  THE   HEALTH    OFFICER 

of  milk  with  17.5  c.c.  of  sulphuric  acid  (sp.  gr.  1.825)  in  the 
flask,  and  centrifuge  the  mixture  four  minutes.  Add  boiling 
water  until  the  contents  begin  to  rise  into  the  neck,  and  centri- 
fuge two  minutes.  Add  more  boiling  water  until  the  contents 
rise  nearly  to  the  top  of  the  graduated  part  of  the  neck,  and  cen- 
trifuge one  minute.  The  melted  fat  will  then  have  collected  as 
a  clear  yellow  oil,  and  its  quantity  may  be  read  by  means  of 
the  graduations  on  the  flask.  The  weight  of  2  c.c.  of  butter- 
fat  is  10  per  cent,  of  the  weight  of  the  17.5  c.c.  of  milk  that  was 
used.  If  the  fat  is  measured  by  0.4  of  the  graduations  on  the 
neck  of  the  flask,  its  quantity  is  0.4  of  10  per  cent.,  or  4  per 
cent,  of  the  milk. 

The  price  of  milk  at  dairies  and  creameries  is  usually  governed 
by  its  percentage  of  fat  as  determined  by  the  Babcock  method. 

Total  Solids. — The  percentage  of  total  sohds  in  milk  may  be 
found  by  evaporating  a  known  quantity  of  milk,  and  comparing 
the  weight  of  the  dry  residue  with  the  weight  of  the  sample  of 
milk. 

There  are  several  formulas  for  calculating  the  percentage  of 
total  solids  when  the  specific  gravity  and  the  percentage  of  fat 
are  known.     A  simple  formula  is  as  follows: 

Percentage  of  total  solids  =  f  -f-  1.2  F.  +  0.14,  in  which  S.  is 
the  two  figures  standing  for  hundredths  and  thousandths  in  the 
number  expressing  the  specific  gravity,  and  F.  is  the  percentage 
of  fat.  For  example:  A  sample  of  milk  has  a  specific  gravity  of 
1.033  and  contains  3.8  per  cent,  of  fat: 


■4" 

= 

8.25 

3.8 

X 

1.2 

= 

4.56 
0.14 

Total  solids 

= 

12.95 

per 

cent, 

Wholesome  Milk. — A  health  officer  is  concerned  chiefly  with 
the  wholesomeness  of  milk  independently  of  its  chemical  com- 
position. Unless  great  care  is  taken  in  its  production,  handling, 
and  keeping,  milk  undergoes  rapid  changes  which  render  it  an 
unwholesome  food,  especially  for  children  and  babies. 

The  changes  are  produced  principally  by  bacteria  which 
enter  the  milk  after  it  has  been  drawn  from  the  cow,  and  which 
multiply  in  the  milk.  Their  source  is  ordinary  dust  and  dirt 
from  the  cows,  stables,  workmen,  utensils,  and  milk  rooms. 
Cleanliness  is  the  principal  condition  on  which  the  wholesome- 
ness of  milk  depends.  Milk  which  is  perfectly  clean  contains 
few  bacteria,  and  will  undergo  changes  so  slowly  that  it  may  be 
marketed  and  kept  for  a  reasonable  length  of  time  before  un- 


MILK  347 

desirable  changes  occur.  The  most  rehablc  test  for  the  whole- 
someness  of  milk  is  the  number  of  bacteria  in  each  cubic  centi- 
meter. First-class  milk  contains  less  than  10,000  bacteria  in 
each  cubic  centimeter.  Milk  of  fair  quality  may  contain  200,- 
000  bacteria,  and  milk  of  poor  quality,  several  million  per 
cubic  centimeter.  Milk  is  seldom  so  dirty  that  it  contains 
millions  of  bacteria  for  some  hours  after  it  has  been  drawn  from 
the  cow.  The  greater  number  of  bacteria  in  the  poorer  grades 
of  milk  consist  of  the  organisms  which  have  multiplied  from  those 
which  were  originally  in  it. 

Sediment  Test. — Milk  that  contains  visible  dirt  in  the  sedi- 
ment is  almost  sure  to  contain  great  numbers  of  bacteria.  If 
particles  of  dirt  can  be  seen  in  the  bottom  of  a  bottle  of  milk, 
that  milk  is  unwholesome,  especially  for  children.  A  test  for 
visible  particles  of  dirt  in  milk  is  to  strain  the  milk  through  a 
pad  of  absorbent  cotton.  Line  a  small  kitchen  funnel  with  a 
layer  of  absorbent  cotton  about  |  inch  thick,  and  pour  the 
contents  of  a  milk  bottle  through  it.  Every  particle  of  dirt 
will  be  clearly  visible  on  the  white  cotton.  There  is  one  form  of 
sediment  tester  in  which  the  milk  is  strained  through  prepared 
disks  of  cotton  which  may  be  preserved  as  a  record  of  the  clean- 
liness of  the  milk.  A  sediment  tester  has  a  considerable  educa- 
tional value  in  demonstrating  dirt  in  milk  to  farmers  and  dairy- 
men. 

Bacterial  Examination. — A  bacterial  examination  of  milk  is 
usually  made  to  determine  the  number  of  bacteria,  regardless  of 
their  kind.  The  examination  consists  either  in  making  cultures 
from  the  milk  and  counting  the  colonies  which  develop;  or  in 
making  a  smear  of  the  undiluted  milk  and  counting  the  indi- 
vidual bacteria. 

The  method  of  examining  milk  by  cultures  is  as  follows: 
Make  a  series  of  dilutions  by  adding  1  c.c.  of  milk  to  9  c.c.  of 
sterile  water;  1  c.c.  of  this  dilution  to  9  c.c.  of  water,  and  so  on. 
The  amount  of  milk  in  each  cubic  centimeter  of  these  dilutions 
will  be  To,  Tw,  TFoo  c.c,  etc.  Make  a  culture  from  each  dilu- 
tion by  placing  1  c.c.  on  a  Petri  dish  and  adding  the  liquefied 
culture-medium.  Incubate  the  culture  for  forty-eight  hours  at 
the  body  temperature  and  count  the  colonies  which  develop. 
The  number  of  bacteria  in  each  cubic  centimeter  of  milk  will  be 
indicated  by  the  number  counted  in  a  dish,  multipKed  by  the 
dilution  of  the  milk  that  was  poured  into  the  dish.  If  too  high 
a  dilution  is  used,  the  number  of  colonies  will  be  small;  and  if 
too  low  a  dilution,  the  number  of  colonies  will  be  so  large  as  to  be 
uncountable.  The  most  accurate  result  is  that  obtained  from  a 
dish  on  which  about  200  colonies  have  developed.     Milk  of 


348  THE  HEALTH   OFFICER 

poor  quality  may  require  a  dilution  of  1  :  10,000  or  1  :  100,000. 
In  the  routine  examination  of  milk  in  New  York  City  two 
dilutions  are  used,  one  a  1  :  100,  and  the  other  a  1  :  10,000 
dilution. 

The  method  of  directly  counting  bacteria  in  milk  is  as  fol- 
lows: Using  a  standard  loop  of  platinum  wire  that  will  take 
rsTj  c.c.  of  milk,  smear  a  loopful  evenly  upon  a  sUde  over  a  ruled 
area  1  cm.  square,  and  allow  it  to  dry.  Extract  the  fat  with 
xylol.  Fix  the  film  with  alcohol  and  stain  it  with  methylene- 
blue.  Examine  the  specimen  with  an  oil-immersion  lens  whose 
field  of  view  has  an  area  of  0.16  millimeter,  and  count  the  bac- 
teria in  100  fields.  This  number  multiplied  by  5000  gives  the 
number  of  bacteria  per  cubic  centimeter  of  milk.  If  the  tube 
length  of  the  microscope  is  adjusted  to  such  a  length  that  the 
field  of  view  has  a  diameter  of  0.16  millimeter,  the  area  of  the 
field  will  be  0.0002  cm.,  and  of  100  fields,  0.002  cm.  But  since 
the  depth  of  the  film  is  you  cm.,  the  volume  of  milk  examined 
in  100  fields  is  0.0002  c.c.  or  5iroo  c.c.  If  the  number  of  bac- 
teria per  cubic  centimeter  is  only  a  few  thousand,  most  of  the 
fields  examined  will  contain  no  bacteria  at  all;  but  if  the  bac- 
teria number  hundreds  of  thousands,  a  few  will  appear  in  each 
field.  The  method  of  direct  examination  of  milk  bacteria  is 
used  principally  in  field  work  to  make  an  approximate  estimate 
of  the  quality  of  milk  at  the  receiving  dairies.  A  few  slides  can 
be  quickly  made  and  examined  in  an  office,  and  the  examiner 
can  give  an  opinion  at  once  whether  or  not  the  milk  is  of  fair 
quality. 

The  number  of  bacteria  found  by  the  direct  method  of  ex- 
amination is  usually  at  least  double  the  number  found  by  cul- 
ture method,  for  in  the  direct  method  every  bacterium  is  counted, 
whether  it  is  living  or  dead,  or  is  single  or  in  a  clump.  In  the 
cultural  method  only  living  bacteria  are  counted,  and  since  each 
clump  forms  only  a  single  colony,  it  is  counted  as  a  single  bac- 
terium. The  cultural  method  is  the  standard  one  that  is  used 
in  laboratory  examinations. 

Taking  Samples. — A  health  officer  frequently  has  to  take 
samples  of  milk  for  bacterial  examination.  The  standard  outfit 
supplied  to  milk  inspectors  in  New  York  City  consists  of  steril- 
ized ^-ounce  bottles;  a  box  of  sterilized  tubes  of  aluminum,  each 
about  I  inch  in  diameter  and  18  inches  long,  for  taking  samples; 
and  a  carrying  tray  in  which  the  boxes  of  samples  may  be  packed 
in  ice.  A  health  officer  can  obtain  similar  bottles  and  tubes  of 
glass  at  a  drug  store,  sterilize  them  by  boiling,  pack  the  samples 
in  ice,  and  see  that  they  reach  the  laboratory  as  soon  as  pos- 
sible.    It  is  best  to  send  them  by  special  messenger  in  order  to 


MILK  349 

avoid  delay  and  legal  questions  regarding  the  identity  of  the 
samples. 

Bacteria  are  not  evenly  distributed  through  a  bottle  or  can 
of  milk,  but  their  number  is  greater  in  the  cream  layer  and 
sediment,  and  least  in  the  center  of  the  container.  It  is  neces- 
sary to  shake  the  container  or  stir  the  milk  in  order  to  obtain  a 
true  sample.  Use  a  clean  implement  for  stirring  the  milk  in 
each  container,  and  a  fresh  tube  for  taking  each  sample.  If 
milk  is  bottled,  a  health  officer  may  send  a  whole  bottle  to  the 
laboratory. 

Bactericidal  Action  of  Milk. — After  milk  has  been  drawn  from 
a  cow,  the  number  of  colonies  of  bacteria  that  may  be  grown  from 
a  sample  diminishes  for  a  few  hours,  and  then  increases.  The 
apparent  diminution  in  the  number  of  bacteria  has  been  taken 
as  an  indication  that  milk  contains  a  ferment  that  destroys 
bacteria.  The  diminution  may  be  explained  by  the  death  of 
those  which  require  a  temperature  of  the  body  for  their  life  and 
growth.  It  may  also  be  explained  by  the  clumping  or  agglutina- 
tion of  the  bacteria,  since  each  clump  will  make  only  a  single 
colony  in  the  culture. 

Kinds  of  Bacteria  in  Milk.^The  bacteria  that  are  usually 
found  in  milk  may  be  divided  into  four  groups:  1,  those  produc- 
ing lactic  acid;  2,  those  of  fermentation  and  decay;  3,  those  of 
human  diseases;  4,  those  that  are  inert. 

Lactic  Acid  Bacteria. — Bacteria  which  produce  lactic  acid 
are  the  cause  of  the  souring  of  milk.  Fresh  milk  is  only  very 
faintly  acid.  Its  casein  is  held  in  solution  by  phosphates.  When 
lactic  acid  is  produced  in  considerable  quantity,  it  unites  with 
the  phosphates,  and  the  casein  then  solidifies  and  separates  a 
curd. 

Lactic  acid,  and  other  substances  produced  by  the  lactic 
acid  bacteria,  are  not  harmful  to  human  beings,  and  milk  soured 
by  pure  cultures  of  the  bacteria  is  wholesome  even  for  children 
and  babies.  Koumiss  and  other  preparations  of  soured  milk 
are  produced  by  the  growth  of  pure  cultures  of  special  forms  of 
the  lactic  acid  bacteria.  The  lactic  acid  bacteria  restrain  the 
growth  of  most  other  kinds  of  bacteria,  and  so  food  products, 
such  as  butter  or  cheese,  which  are  made  from  soured  milk,  are 
usually  wholesome  whether  the  souring  is  done  by  means  of 
pure  cultures  or  by  natural  processes. 

The  lactic  acid  bacteria  usually  grow  more  rapidly  than 
most  other  kinds.  If  they  have  not  multiplied  sufficiently  to 
give  milk  an  acid  reaction  or  sour  taste,  it  is  usually  considered 
that  other  kinds  of  bacteria  have  not  multiplied  sufficiently  to 
render   the  milk  unwholesome.     The  presence  or  absence   of 


350  THE   HEALTH    OFFICER 

souring  is  a  fairly  reliable  test  of  the  wholesomeness  of  milk  for 
adults,  but  not  of  milk  for  babies. 

Bacteria  of  Fermentation  and  Decay. — Unpleasant  odors  and 
tastes  in  milk  may  be  due  to  the  food  of  the  cows,  or  to  gases 
absorbed  from  substances  stored  near  the  milk;  but  some  of 
them  are  caused  by  the  ordinary  bacteria  of  dust  and  dirt,  and 
of  the  soil  and  air.  They  consist  largely  of  those  of  fermenta- 
tion and  decay  which  multiply  manyfold  in  milk  and  produce 
a  series  of  changes  which  would  finally  result  in  the  decomposi- 
tion and  putrefaction  of  the  milk  if  they  should  be  allowed  to 
continue.  These  bacteria  and  the  substances  which  they  pro- 
duce are  unwholesome  and  often  poisonous,  especially  for 
babies.  They  may  cause  summer  diarrhea  in  infants.  Some 
milder  forms  of  the  sickness  seem  to  be  the  result  of  a  suscepti- 
bility of  young  children  to  the  proteins  that  are  usually  found  in 
the  lower  grades  of  market  milk  as  a  result  of  bacterial  growth. 
The  repeated  use  of  the  milk  gradually  induces  an  immunity 
which  enables  older  children  to  take  even  the  poorer  grades  of 
milk  with  safety.  A  baby  may  become  immune  to  the  protein 
of  the  milk  which  it  ordinarily  takes,  and  may  be  made  sick  when 
its  food  is  changed  to  milk  which  is  of  a  better  grade,  but  whose 
bacterial  growth  is  different  from  that  to  which  it  has  been 
accustomed.  Preventing  bacteria  of  dust  and  dirt  from  entering 
milk  is  one  of  the  principal  things  for  a  dair}Tnan  to  have  in 
mind  in  producing  milk  that  has  a  high  grade  and  is  wholesome. 

Whether  the  bacteria  of  fermentation  and  decay  or  those 
producing  lactic  acid  grow  the  faster  will  depend  lar^ Jy  on  the 
temperature  at  which  milk  is  kept.  If  the  temperature  is  that  of 
an  ordinary  living-room  or  higher,  the  bacteria  of  fermentation 
and  decay  are  likely  to  predominate  and  render  the  milk  danger- 
ous before  it  sours.  If  it  is  kept  at  a  temperature  of  an  ordinary 
ice-box  or  lower,  the  lactic  acid  bacteria  usually  predominate 
and  the  milk  remains  w^holesome  until  it  turns  sour. 

Bacteria  are  necessary  in  making  butter  and  cheese,  for  the 
products  that  are  made  from  sterilized  milk  are  almost  taste- 
less. The  quality  of  cheese  depends  largely  on  the  grow^th  of 
special  kinds  of  bacteria  which  develop  the  special  flavors  and 
tastes  of  the  various  brands.  The  beneficial  bacteria  in  milk 
and  cream  are  of  the  lactic  acid  type,  and  as  they  grow,  they 
tend  to  kill  the  other  kinds  of  bacteria,  including  disease  germs. 
For  this  reason  butter  and  cheese  made  from  a  poor  quality  of 
milk  may  be  wholesome  and  free  from  harmful  bacteria.  Still, 
this  disinfecting  action  is  not  sure,  and  a  health  oflicer  must 
consider  butter,  cheese,  and  other  products  to  be  dangerous  when 
they  are  produced  from  milk  containing  disease  germs. 


MILK  351 

Disease  Germs  in  Milk. — Milk  sometimes  contains  the  spe- 
cific bacteria  which  produce  diseases  in  human  beings.  The 
presence  of  the  germs  nearly  always  becomes  known  only  by 
an  outbreak  of  sickness  among  those  who  drink  the  milk,  for 
the  germs  are  usually  very  few  in  number.  A  dozen  germs  in 
each  cubic  centimeter  of  milk  would  be  sufficient  to  cause  a 
disease,  but  it  is  almost  impossible  to  recognize  this  number  in 
a  sample  which  contains  thousands  of  other  kinds  of  bacteria. 
Disease  germs  may  be  suspected  when  the  milk  is  handled  by  a 
workman  who  has  a  transmissible  disease,  for  the  most  common 
source  of  the  germs  is  a  person  who  handles  the  milk. 

Disease  germs  reach  the  milk  by  means  of  the  hands  of  those 
who  handle  the  milk,  of  workmen  coughing  or  sneezing  over 
the  milk,  or  of  polluted  water  used  in  washing  the  milk  con- 
tainers. The  germs  of  bovine  tuberculosis  and  of  a  few  other 
cow  diseases  may  also  be  found  in  milk,  and  may  be  transferred 
to  human  beings. 

The  common  diseases  which  have  been  proved  to  be  trans- 
mitted from  person  to  person  by  means  of  milk  after  it  has  been 
drawn  from  the  cow  are  tuberculosis,  septic  sore  throat,  scarlet 
fever,  typhoid  fever,  and  diphtheria.  The  New  York  State 
Sanitary  Code,  in  the  [chapter  on  milk,  mentions  these  diseases, 
and  also  cholera,  amebic  or  bacillary  dysentery,  paratyphoid 
fever,  and  smallpox  as  likely  to  be  milk-borne.  The  code  also 
requires  that  every  case  of  any  of  these  diseases  on  a  dairy 
farm  shall  be  reported  to  the  State  Commissioner  of  Health 
immediately,  and  that  the  sale  of  dairy  products  from  the  dairy 
farm  in  which  the  sick  person  lives  or  works  shall  be  stopped, 
except  under  the  following  conditions: 

"(a)  That  such  foods  are  not  brought  into  the  house  where 
such  case  exists. 

"(b)  That  all  persons  coming  in  contact  with  such  foods  eat, 
sleep,  and  work  wholly  outside  such  house. 

"(c)  That  such  persons  do  not  come  in  contact  in  any  way 
with  such  house,  or  its  inmates,  or  contents. 

"(d)  That  said  inmates  are  properly  isolated  and  separated 
from  all  other  parts  of  said  farm  or  dairy,  and  efficiently  cared  for. 

"(e)  That  a  permit  be  issued  by  the  health  officer." 

For  characteristics  of  a  milk-borne  epidemic  see  page  173. 

The  duty  of  a  health  ofiicer  is  plain  when  a  w^orkman  in  a 
dairy  has  a  communicable  disease,  but  he  is  often  in  doubt  when 
the  disease  is  mild  or  obscure.  Yet  a  person  ha\'ing  a  disease 
in  a  mild  form  is  more  likely  to  infect  milk  than  one  sick  in  bed, 
for  he  continues  at  work.  A  safe  course  for  a  health  ofl&cer  to 
follow  when  in  doubt  regarding  a  disease  on  a  dairy  farm  is  to 


352  THE  HEALTH   OFFICER 

ad\ise  that  every  person  who  has  a  sore  throat  or  intestinal 
disturbance  shall  be  excluded  from  the  dairy.  He  can  usually  get 
a  dairjTnan  to  follow  his  ad\ice  by  pointing  out  to  him  the  money 
value  of  avoiding  all  suspicion  regarding  the  milk. 

Transmissibility  of  Bovine  Diseases  to  Man. — A  few  diseases 
which  primarily  affect  cows  may  be  transmitted  to  human 
beings  by  means  of  the  milk  of  diseased  animals.  ISIilk  from 
unhealthy  cows  is  always  to  be  regarded  with  suspicion,  and 
public  sentiment  vdW  uphold  a  health  officer  in  excluding  such 
milk  from  the  market,  even  though  no  disease  germs  or  unwhole- 
some products  can  be  demonstrated  in  it.  It  is  to  a  dairy- 
man's tinancial  benefit  that  he  exclude  all  diseased  stock  from 
his  herd.  A  health  officer  is  frequently  consulted  regarding  the 
health  of  cows,  and  he  ought  to  know  the  signs  and  the  efifects 
of  diseases  that  may  be  transmitted  by  means  of  milk. 

Tuberculosis. — The  principal  disease  which  is  transmitted  to 
human  beings  by  means  of  milk  from  diseased  animals  is  tuber- 
culosis caused  by  the  bo\dne  type  of  tubercle  bacilli.  There 
was  formerly  much  controversy  whether  or  not  bovine  tuber- 
culosis could  be  transmitted  to  human  beings.  Accurate  tests 
and  extended  observations  prove  that  adults  are  immune  to 
bovine  tubercle  germs,  but  that  children  are  not.  Boxine  ba- 
cilli are  seldom  found  in  tubercular  lungs,  and  less  rarely  in 
affected  bones  and  joints;  but  they  are  frequently  the  cause  of 
tuberculosis  of  the  glands  of  the  neck,  of  the  abdominal  organs, 
and  of  generalized  tuberculosis.  About  10  per  cent,  of  the 
children  who  die  from  tuberculosis  have  the  bo\'ine  t^pe  of 
germs. 

Tubercle  bacilli  pass  from  the  cow  to  human  beings  by  means 
of  milk  and  seldom  by  any  other  route.  The  recognition  of 
tubercle  germs  in  milk  cannot  be  made  with  certainty  by  stain- 
ing methods  or  a  microscopic  examination,  for  many  kinds  of 
hay  bacilli  are  acid  fast,  and  almost  exactly  resemble  tubercle 
bacilli  in  form  and  staining  qualities  (page  292).  The  test  for 
tubercle  bacilli  in  milk  is  made  by  centrifuging  the  milk  and 
injecting  some  of  the  sediment  and  some  of  the  cream  into  guinea- 
pigs  (page  293). 

Tuberculosis  may  affect  almost  any  organ  of  a  cow's  body. 
If  the  udder  is  affected,  the  germs  may  be  found  in  the  milk 
when  it  is  drawn  from  the  cow;  but  most  of  the  tubercle  germs 
in  market  milk  come  from  manure  and  other  dirt  containing 
germs  which  have  been  expelled  from  the  respirator}-  and  in- 
testinal tracts  of  diseased  cows. 

Two  methods  of  detecting  tuberculosis  in  cows  are:  1,  a 
physical  examination,  and  2,  the  tuberculin  test.     Tuberculosis 


MILK  353 

may  be  suspected  when  a  cow  has  a  cough,  or  is  losing  flesh 
without  apparent  cause,  or  has  enlarged  glands,  or  an  intestinal 
disturbance.  The  disease  gives  the  same  physical  signs  in  a  cow 
as  in  a  human  being. 

Many  cows  give  off  tubercle  bacilli  before  the  signs  of  the 
disease  are  evident.  The  disease  may  be  detected  in  its  early 
stages  by  means  of  the  tuberculin  test,  which  is  performed  as 
follows:  Take  the  cow's  temperature  at  three-hour  intervals  for 
twenty-four  hours  in  order  to  obtain  the  usual  range  of  tempera- 
ture of  that  particular  cow.  Inject  the  tuberculin  subcutane- 
,  ously  and  continue  to  take  its  temperature  for  another  twenty- 
four  hours,  A  rise  of  temperature  of  2°  or  3°  F.  indicates  tuber- 
culosis. 

The  tuberculin  test  requires  a  considerable  degree  of  skill 
and  judgment,  and  is  subject  to  many  sources  of  error.  Many 
cows  with  advanced  tuberculosis  do  not  react  to  the  test,  but 
these  usually  show  evident  physical  signs  of  the  disease.  After 
a  cow  has  been  injected  with  tuberculin,  there  will  usually  be  no 
reaction  to  another  test  made  within  a  month  afterward.  How- 
ever, if  a  test  is  made  in  the  proper  manner  by  a  skilled  and 
honest  veterinarian,  it  is  a  reliable  indication  of  the  presence  or 
absence  of  tuberculosis. 

Tuberculosis  is  common  among  cattle.  If  a  cow  is  free  from 
the  disease,  the  animal  may  catch  it  and  develop  it  in  an  ad- 
vanced form  in  a  few  months.  It  is  a  routine  practice  in  the 
best  dairies  to  apply  the  tuberculin  test  to  the  entire  herd  every 
six  months,  and  to  remove  all  the  animals  that  react. 

Tubercular  cows  may  be  divided  into  two  groups — those 
which  give  off  tubercle  bacilli  and  those  which  do  not,  or  the 
spreaders  and  the  non-spreaders.  The  spreaders  are  those 
whose  udders,  lungs,  or  intestines  contain  open  sores  from  which 
the  germs  may  escape.  Non-spreaders  may  not  be  dangerous 
so  long  as  we  are  sure  that  they  do  not  give  off  tubercle  bacilH, 
but  they  may  become  spreaders  at  any  time.  A  tubercular  cow 
is  a  source  of  danger  to  other  cows  and  to  human  beings,  and 
the  control  of  all  affected  cows  is  necessary  for  the  preservation 
of  pubHc  health.  The  laws  of  New  York  State  require  that  all 
cattle  known  to  have  tuberculosis  shall  either  be  slaughtered  or 
else  be  isolated  under  a  permit  from  the  State  Commissioner  of 
Agriculture,  and  their  milk  must  not  be  sold  or  manufactured 
into  butter  or  cheese  unless  it  is  first  pasteurized  at  a  tempera- 
ture of  185°  F.  (Agricultural  Law,  Section  94). 

Inflamed  Udders. — An  inflammation,  or  hardening,  or  caking 
of  the  udder  frequently  occurs  in  cows,  and  the  milk  of  such 
cows  usually  contains  flakes  of  curds  derived  from  the  hardened 

23 


354  THE   HEALTH    OFFICER 

area.  The  disease  is  usually  caused  by  bacteria  of  a  strepto- 
coccus type,  which  do  not  seem  to  be  virulent  to  human  beings. 
It  usually  affects  only  one-quarter  of  the  udder,  and  dairymen 
often  throw  away  the  milk  from  that  part  and  use  the  milk  from 
the  rest  of  the  udder.  This  is  a  dangerous  practice,  and  it  is 
the  duty  of  a  health  officer  to  exclude  all  the  milk  from  an  af- 
fected cow  as  long  as  the  disease  lasts. 

The  germs  of  human  septic  sore  throat  may  grow  in  the  ud- 
der of  a  cow,  but  they  are  only  mildly  virulent  to  a  cow  and 
usually  produce  only  a  slight  inflammation.  A  cow  that  har- 
bors the  germs  is  simply  a  carrier,  and  will  soon  e.xcrete  the 
germs,  provided  it  is  not  continually  reinfected  by  a  human  car- 
rier (page  227). 

Contagious  Abortion. — This  condition  is  caused  by  a  specific 
bacterium  which  is  transmitted  by  means  of  the  male  animal. 
It  is  possible  that  the  milk  of  an  affected  animal  may  be  un- 
wholesome to  infants.  The  disease  does  not  usually  have  a 
great  effect  on  the  health  of  the  cows,  but  its  presence  in  a  herd 
produces  great  financial  loss  on  account  of  the  inabihty  of  cows 
to  bear  calves. 

OtJicr  Diseases. — The  germs  of  parat}'phoid  fever  may  grow 
in  cows  and  produce  a  form  of  septicemia.  The  meat  of  af- 
fected animals  is  the  cause  of  much  of  the  so-called  ptomain 
poisoning  among  human  beings,  and  their  milk  is  a  grave  source 
of  danger. 

Foot-and-mouth  disease  in  cows  produces  a  sickness  which 
may  be  compared  with  measles  in  human  beings.  It  may  be 
recognized  by  an  eruption  or  sores  in  the  mouth,  and  by  a  sud- 
den fever  and  a  fall  in  the  milk  production.  It  is  seldom  fatal, 
but  an  affected  cow  will  produce  only  a  small  quantity  of  milk 
for  a  year  or  more.  The  disease  causes  great  financial  loss,  and 
may  also  be  transmitted  to  human  beings.  It  is  as  contagious 
as  measles,  and  the  federal  laws  require  the  immediate  destruc- 
tion of  an  entire  herd  when  a  single  one  of  the  animals  is  found 
to  be  affected. 

Cowpox,  or  vaccinia,  may  be  transmitted  to  man.  It  fre- 
quently exists  in  a  mild  form,  and  is  usually  mistaken  for  ordi- 
nary sores  on  the  teats.  It  seems  to  have  no  bearing  on  public 
health,  but  a  health  officer  should  remember  the  possibility  of 
the  disease. 

Anthrax,  glanders,  rabies,  and  tetanus  are  rare  diseases  which 
a  health  officer  may  unexpectedly  find  in  a  dairy,  and  which 
require  an  immediate  quarantine  of  the  affected  animals  in  order 
to  prevent  the  possible  transmission  of  the  diseases  to  persons. 

Pasteurization. — Milk  free  from  disease  germs  may  be  pro- 


MILK  355 

duced  from  healthy  cows  by  healthy  dairymen  who  follow  clean 
methods  of  production.  But  it  is  not  always  possible  to  be  sure 
of  the  healthfulness  of  the  cows  and  workmen,  or  of  cleanliness 
in  producing  and  handling  milk.  Pasteurization  supplements 
clean  methods  of  production,  and  insures  a  milk-supply  that  is 
free  from  disease  germs.  It  will  not  undo  all  the  evil  effects  of 
disease  germs  and  dirt,  or  restore  freshness  to  milk  that  is 
already  spoiled,  but  it  will  destroy  the  specific  germs  that  pro- 
duce human  diseases.  If  a  health  officer  has  good  reasons  to 
suspect  that  a  certain  milk-supply  contains  disease  germs,  he 
may  allow  the  milk  to  be  sold,  provided  it  is  efficiently  pasteur- 
ized. 

The  milk-supply  of  New  York  City  comes  from  a  radius  of 
hundreds  of  miles,  and  the  number  of  producers  is  so  large  that 
a  strict  supervision  of  the  dairies  and  the  workmen  is  impos- 
sible. When  a  milk-borne  outbreak  of  disease  has  occurred  in 
the  city,  it  has  been  difficult  or  impossible  to  trace  the  germs  to 
the  guilty  dairy.  The  Department  of  Health,  therefore,  re- 
quires that  all  milk  sold  from  ordinary  milk  wagons  and  depots 
shall  be  pasteurized. 

Pasteurization  means  heating  milk  to  a  temperature  and  for 
a  length  of  time  which  is  sufficient  to  kill  the  harmful  bacteria 
without  producing  undesirable  or  harmful  changes  in  the  milk 
itself.  The  standards  of  temperature  and  time  of  pasteuriza- 
tion vary  considerably.  The  standard  fixed  by  the  sanitary  code 
of  New  York  State  is  that  milk  shall  be  subjected  to  a  tempera- 
ture of  142°  to  145°  F.  for  not  less  than  thirty  minutes.  A 
boiling  temperature  would  render  milk  practically  sterile,  but  it 
would  give  the  milk  an  unpleasant  taste,  and  would  produce 
other  undesirable  changes  in  the  milk.  When  pasteurization  is 
properly  done,  the  milk  is  unchanged  in  its  taste  and  appearance, 
in  its  physical  and  chemical  properties,  and  in  its  digestibihty 
and  nutritive  value. 

It  is  sometimes  claimed  that  an  exclusive  diet  of  pasteurized 
milk  may  produce  scurvy  and  rickets  in  babies.  Any  form  of 
milk  fed  alone  for  months  may  produce  evidences  of  malnutri- 
tion. A  teaspoonful  of  orange- juice  three  or  four  times  a  week 
will  supply  the  missing  food  elements  and  prevent  scurvy  and 
rickets  when  pasteurized  milk  is  fed  to  infants. 

The  only  object  of  proper  pasteurization  is  to  kill  bacteria 
in  milk.  It  will  not  destroy  toxins  and  other  poisons  that  were 
formed  in  the  milk  before  it  was  pasteurized.  The  New  York 
State  Sanitary  Code  Torbids  the  labeling  of  milk  as  pasteurized 
unless  it  was  sweet  and  wholesome  when  it  was  pasteurized,  as 
proved  by  a  bacterial  count. 


356  THE  HEALTH   OFFICER 

Pasteurized  milk  will  keep  sweet  longer  than  untreated  milk, 
but  it  will  tinally  become  sour  and  spoiled,  for  the  low  tempera- 
ture of  the  pasteurization  does  not  kill  the  more  persistent 
bacteria  or  their  spores.  It  is  necessary  to  take  the  same  care 
of  pasteurized  milk  as  of  raw  milk. 

Test  of  Efficiency  of  Pasteurization. — A  standard  test  for  the 
efficiency  of  pasteurization  is  the  determination  of  the  presence 
of  living  colon  baciUi  in  milk.  Colon  bacilli  derived  from  the 
intestine  of  the  cow  are  found  in  all  commercial  milk.  They 
are  somewhat  more  resistant  to  heat  than  the  specific  bacteria 
of  diseases.  If  all  the  colon  bacilli  are  killed  by  the  process  of 
pasteurization,  we  may  be  confident  that  the  bacteria  of  human 
diseases  are  also  killed;  while  if  the  colon  bacilh  survive,  there  is 
a  chance  that  some  bacteria  of  disease  may  survive.  The  tests 
are  the  same  as  those  for  colon  bacilli  in  water,  and  are  made 
by  inoculating  milk  into  femientation  tubes  of  dextrose  broth, 
and  by  confirmatory  tests  of  platings  upon  special  media' (page 
456). 

Commercial  Methods  of  Pasteurization. — There  are  two  meth- 
ods of  pasteurizing  milk:  the  flash  and  the  holding  systems. 
The  flash  system  consists  in  passing  the  milk  through  tubes 
which  quickly  raise  its  temperature  to  160°  or  170°  F.,  and  then 
through  other  tubes  which  make  it  ice  cold.  The  whole  cycle 
of  heating  and  cooling  requires  only  about  five  seconds.  This 
system  is  often  uncertain  in  its  results,  and  requires  constant 
and  expert  attention.  The  comparatively  high  temperature  of 
the  process  is  likely  to  give  the  milk  an  unpleasant  taste. 

The  holding  process  consists  in  heating  the  milk  to  145°  F. 
and  holding  it  at  that  temperature  in  a  tank  for  at  least  half 
an  hour.  The  results  of  this  method  are  more  uniform  and 
efficient  than  those  of  the  flash  method.  The  low  temperature 
does  not  affect  the  taste  of  the  milk,  while  the  length  of  the  ap- 
plication of  the  heat  insures  the  death  of  the  bacteria. 

Pasteurizing  milk  on  a  commercial  scale  requires  a  rather 
complicated  and  expensive  outfit,  and  a  considerable  degree  of 
skill  in  its  operation.  Great  cleanliness  must  be  observed,  and 
all  parts  of  the  apparatus  must  be  thoroughly  cleaned  and 
sterilized  after  it  is  used,  and  all  joints  and  connections  must  be 
maintained  in  a  perfect  condition,  for  a  bit  of  milk  or  slime 
left  in  any  part  may  reseed  the  entire  supply  with  bacteria  that 
are  undesirable  or  harmful.  The  smallest  apparatus  that  is 
economic  and  efficient  is  designed  for  about  400  quarts  daily. 
When  a  smaller  quantity  is  pasteurized,  the  variations  in  tem- 
perature render  the  process  uncertain.  The  large  size  of  the 
plant  renders  pasteurization  impracticable  for  a  rural  dealer 


MILK  357 

whose  daily  output  is  100  quarts  or  less.  There  is  a  great  need 
for  a  pasteurizer  with  a  daily  capacity  of  50  quarts. 

An  ideal  method  of  pasteurization  is  first  to  bottle  the  milk 
and  then  to  heat  both  the  milk  and  the  container.  I'his  process 
is  not  practicable  on  a  commercial  scale  on  account  of  the  cost 
of  heating  the  bottles  themselves,  and  of  the  quantity  of  heat 
required  to  heat  the  space  in  which  the  bottles  are  held  during 
the  process.  A  considerable  time  is  also  required  to  heat  the 
milk  in  quart  units  and  to  cool  it  again. 

Home  Pasteurization. — When  a  community  is  threatened 
with  an  epidemic,  or  when  an  infant's  food  must  be  prepared, 
a  health  officer  may  be  asked  how  to  pasteurize  milk  at  home. 
The  outfit  needed  to  pasteurize  a  few  pints  of  milk  in  the  kitchen 
is  a  double  boiler  and  a  thermometer.  The  pasteurization  can- 
not be  done  accurately  unless  the  temperature  is  regulated 
exactly.  One  can  use  a  cheap  bath  thermometer  with  the  wooden 
case  removed.  Heat  the  milk  in  the  inner  container  and  stir  it 
frequently.  Watch  the  temperature,  and  when  the  thermometer 
reads  145°  F.,  remove  the  boiler  to  a  cooler  part  of  the  stove. 
Continue  to  watch  the  temperature  and  to  maintain  it  between 
140°  and  145°  F.  for  thirty  minutes.  Then  cool  the  milk  in  an 
ice-box  or  in  fresh  water  from  a  pump  or  well.  A  person  will 
readily  learn  the  exact  amount  of  fire  and  time  to  be  used,  and 
the  proper  position  of  the  container  on  the  stove,  and  will  then 
be  able  to  pasteurize  the  milk  with  as  great  ease  and  certainty 
as  to  cook  a  beefsteak. 

Emergency  Pasteurization. — A  health  officer  may  suddenly  be 
confronted  with  the  necessity  of  pasteurizing  the  output  of  a 
dairy  on  account  of  the  discovery  of  a  case  of  septic  sore  throat 
or  scarlet  fever  or  other  disease  which  may  infect  the  milk. 
If  the  dairy  is  provided  with  steam  for  heating  the  water  used 
in  washing  the  containers,  or  with  other  facilities  for  heating  a 
large  quantity  of  water,  a  can  or  two  of  milk  may  be  pasteurized 
by  a  method  like  that  used  in  pasteurizing  milk  in  the  home. 
Prepare  a  vat  or  deep  tub  of  boiling  water.  Set  a  can  or  deep 
pail  containing  the  milk  in  it,  and  keep  the  water  at  a  boiling 
temperature.  Stir  the  milk  frequently,  and  take  its  tempera- 
ture every  few  minutes.  When  the  temperature  reaches  145°  F. 
remove  the  can  from  the  water  and  protect  it  from  drafts.  A 
40-quart  can  will  require  about  thirty  minutes  to  reach  a  tem- 
perature of  145°  F.,  and  will  remain  above  140°  F.  for  thirty 
minutes  more. 

Cooling  Milk. — It  is  almost  impossible  to  produce  milk  free 
from  bacteria,  or  to  destroy  all  the  bacteria  by  pasteurization. 
It  is,  therefore,  necessary  to  prevent  bacteria  from  multiplying 


358  THE  HEALTH   OFFICER 

in  milk.  The  only  allowable  method  of  preserving  milk  on  a 
commercial  scale  is  by  cooling  it.  A  low  temperature  restrains 
the  growth  of  all  kinds  of  bacteria.  The  degree  of  temperature 
needed  to  preserve  milk  will  depend  largely  on  the  length  of 
time  that  the  milk  is  to  be  kept.  A  temperature  of  60°  F. 
will  be  sufficient  if  the  milk  is  to  be  used  within  twenty-four 
hours.  The  milk-supply  of  New  York  City  is  often  four  days 
old  when  it  reaches  the  consumer;  and  the  Department  of  Health 
therefore  requires  that  milk  shall  be  kept  at  or  below  40°  F. 
during  its  transportation. 

Preservatives. — Bacteria  in  milk  may  be  destroyed  by  the 
use  of  chemicals,  such  as  peroxid  of  hydrogen,  borax,  or  salicylic 
acid.  Any  chemical  is  likely  to  change  the  composition  of  milk 
and  to  make  it  unwholesome  whether  or  not  the  chemical  itself 
is  harmful.  The  use  of  any  preservati\'e  in  milk  is  forbidden 
by  law  in  New  York  State  (Agricultural  Law,  Sections  30-34). 

THE  PRODUCTION  OF  WHOLESOME  MILK 
The  wholesomeness  of  milk  depends  principally  on  the 
degree  of  its  freedom  from  bacteria  or  their  products.  It  is 
almost  impossible  to  produce  milk  that  is  entirely  free  from 
bacteria,  for  some  bacteria  are  found  in  the  openings  of  the 
milk-ducts  of  healthy  cows  and  for  a  considerable  distance  up 
the  ducts.  By  far  the  greater  number  of  bacteria  in  milk  come 
from  ordinary  dirt,  and  may  be  kept  out  of  the  milk  by  cleanly 
methods  of  producing  and  handling  the  milk.  The  few  bac- 
teria that  are  found  in  even  the  best  milk  may  multiply  to 
millions  and  may  make  the  milk  unwholesome  unless  great  care 
is  taken  to  prevent  their  growth  and  increase.  The  production 
of  wholesome  milk  on  a  commercial  scale  requires  (1)  healthy 
cows,  (2)  cleanliness  through  all  stages  of  its  production,  and 
(3)  the  application  of  cold  to  prevent  the  growth  of  bacteria 
during  the  transportation  and  storage  of  the  milk. 

Score  Card. — The  details  of  equipment  and  methods  which 
are  necessary  in  producing  wholesome  milk  are  enumerated  on  a 
standard  score  card  which  was  devised  by  the  Bureau  of  Animal 
Industry  of  the  United  States  Department  of  Agriculture.  A 
copy  of  this  score  card  is  found  on  page  359.  Other  systems  of 
scoring  have  been  adopted  by  New  York  City  and  other  munici- 
pahties,  but  the  essential  principles  are  the  same  in  all. 

Each  item  on  a  score  card  is  assigned  a  value  depending  on 
its  importance  in  influencing  the  bacterial  count  of  milk.  For 
example,  perfect  cleanliness  of  the  cows  counts  8,  while  cleanli- 
ness of  the  stable  floor  counts  2.  The  system  is  not  perfect,  for 
the  scoring  is  done  at  infrequent  intervals,  and  an  accident  or 


MILK 


359 


carelessness  between  times  may  allow  dirt  to  enter  the  milk  and 
produce  a  temporary  increase  in  the  bacterial  count. 


OFFICIAL   DAIRY   SCORE   CARD 


Owner  or  lessee  of  farm • • 

P.  0.  Address County  

Total  number  of  cows Number  milking. ....:....  Gallons  of  milk  produced  dafly. 

Product  is  sold  by  producer  in  families,  hotels,  restaurants,  stores,  to 

For  milk  supply  of  •  •••' ' * •"■■ 

Permit  No ■•••• Date  of  inspection 


..dealer. 
191 


EQUIPMENT^ 


COWS 

Health  . . . ., •■  •  •' ••••••■ 

Apparently  in  good  health l 

•It  tested  with  tuberculin  within  a  year  and 
no  tuberculosis  is  found,  or  it  tested  withm 
six  months  and  all  reacting  animals  re- 
moved...,-  : .■•••■;^ 

(If  tested  within  a  year  and  reactmg  animal: 

are  found  and  removed,  3.) . 

Food  (clean  and  wholesome) ; 

■Water  (clean.,and  fresh) ................ . 

STABLES 


SCORE. 


Location  of  stable.. , ..... i 

Well  drained .' ........... 

.  Free  from  contaminating  surroundings. .  ..1 
Construction  of  stable : '. .  • 

Tight,  sound  floor  and  proper  gutter .-.2 

Smooth,  tight  walls  and  ceiling 

Proper.stall,  tie,  and  mahger.. .  ~.   . .-. ... 
Provision  for  light;  Foursq.'ft.  of  glass  percow 

(Threb  sq.  ft.,  3;  2  sq.  ft.,  2;  1  sq.  ft.,  1 
Deduct  for  unevea  distribution.) 

Bedding 

Ventilation. .•■■;,■,■,■•,;•'■ 

Provision  for  fresh  air,  controllable  Hue 

system ; .■.....'.... 3 

(Windows  hinged  at  bottom,!  1.5;  slidmg 
windows,  1;  other  openings,  0.6) 

Cubic  feet  of  space  per  cow,  500  ft '. 

(Lfss  than  500ft.,  2;  less  than.400ft.,  1;  less 

than  300  ft.,  o.) 

Provision  for  controlling  temperature '  1 

UTENSILS 

Cphstruction  and  conditions  of  utensils'. . .: 

iWater  for  cleaning. ■, ■ 

(Clean,  convenient,  and  abundant.) 

Small-top  milking  pail 

Milk  cooler. —  " , ...■■■,• 

Clean  milking  suits , 


MILK  ROOM  OR  MILK  HOUSE 
Location:     Free     from    contaminating    sur- 


roundings 
Construction  of  milk  room 

Floor,  walls  and  ceiling. 

Light,  ventilation,  screens V-..-  1 

Separate    rooms    for   washing   utensils   and 

handling  milk  ... 
Facilities  for  steam 

(Hot  viater,  o.5.) 


Total 


Clean 

(Free  from  visible  dirt,6.> 
STABLES 

Cleanliness  of  stables.., r. 

Floor .2 

Walls , i 

Ceiling  and  ledges ,. 1 

Mangers  and  partitions 1 

Windows 1 

Stable  air  at' milking  time...., ; '. 

Freedom  from  dust 3 

Freedom  from  odors 2 

Cleanliness  of  bedding 

Barnyard 

Clean 1 

Well  drained 1 

Removal  of  manure  daily  to  50  feet  from 
stable,. 


MILK  ROOM  OR  MILK  HOUSE 
Cleanliness  of  milk  room 


UTENSILS  AND  MILKING 

Care  and  cleanliness  of  utensils 

Thoroughly  washed  ..'...,. 2 

Sterilized  in  steam  for  15  minutes 3 

(Placed    over    steam  jet,   or  scalded  with 

boiling  water,  2.) 
Protected  from  contamination 3 

Cleanliness  of  milking , 

Clean,  dry  hands '. . . .  .3 

Udders  washed  and  wiped ;...,...  -6 

(Udders  cleaned  with  moist  cloth,  4;  cleaned 

with,  dry  cloth  or  brush  at  least  15  minutes 

before  milking,  1.) 

HANDLING  THE  MILK 

Cleanliness  of  attendants  in  milk  room ...... 

Milk  removed  immediately  from  stable  with- 
out pouring  from  pail  

Coolecf  immediately  after  milking  each  cow.. 

Cooled  below  50=  F 

(51°  to55»,  4;56o  to  60o,  2.) 

Stored  below  50°  F 

(510  10  55",  2;  56o  to  60o.  1.) 

Transportation  below  SOo  F 

(51°  to  55°,  1.5;  5Go  to  60o,  1.) 

(If  delivered  twice  a  day,  allow  perfect  score 

for  storage  and  transportation.) 


Total 


2 

2 

, 

5 



3 

2 

60 

Equipment....: , ..,. — [—  Methods, 


Note  1. — ^If  any  exceptionally  filthy  condition  is  found,  particularly  dirty  utensils,  the  total  score  may 
be  further  limited. 

Note  2. — If  the  water  is  exposed  to  dangerous  contamination,  or  there  is  evidence  of  the  presence  of  a 
dangerous  disease  in  animals  or  attendants,  the  score  shall  be  0. 

*  Alternate.    If  the  milk  is  pasteurized  by  the  holding  process,  score  5. 


A  farmer  or  dairyman  who  sells  milk  is  supposed  to  have  his 
dairy  in  a  reasonably  good  condition,  and  to  exercise  reasonable 
care  at  all  times.  Milk  may  be  made  dangerous  if  it  is  sub- 
jected to  a  single  unclean  process.  A  note  at  the  bottom  of  the 
card  provides  for  limiting  the  score  if  any  condition  is  excep- 


360  THE   HEALTH    OFFICER 

tionally  unfavorable,  and  for  making  the  score  zero  if  the  water 
is  contaminated  or  an  infectious  disease  is  present  in  the  cows  or 
in  the  dairy  attendants. 

Health  officers  and  inspectors  use  the  score  card  in  inspecting 
dairies,  and  in  detecting  conditions  which  may  affect  the  whole- 
someness  of  the  milk.  If  the  stable  and  dairy  are  cleanly  and 
the  methods  which  are  followed  are  satisfactory,  the  milk  will 
usually  have  a  low  bacterial  count.  The  score  card  cannot  take 
the  place  of  a  direct  bacterial  examination  of  the  milk,  but  if 
a  milk  has  a  high  bacterial  count,  an  inspection  of  the  dairy  ac- 
cording to  the  methods  of  the  score  card  will  usually  reveal  the 
source  of  the  contamination,  and  will  lead  to  the  discovery  of 
the  proper  remedy. 

A  health  officer  can  also  use  the  score  card  in  instructing 
farmers  and  dairjTnen  how  to  produce  wholesome  milk.  The 
score  card  includes  nearly  every  point  which  affects  the  bac- 
terial count  of  milk.  The  farmer  who  has  a  copy  of  the  scoring 
of  his  dairy  can  use  it  as  a  guide  in  making  the  necessary  im- 
provements to  his  outfit  and  corrections  to  his  methods. 

Grading  Milk. — The  score  card  is  also  used  in  grading  milk. 
It  does  not  score  the  milk  itself,  but  the  conditions  under  which 
the  milk  is  produced.  It  suggests  the  grade  of  milk  which  we 
may  expect  under  the  conditions  of  the  scoring;  while  a  bac- 
terial count  reveals  the  actual  condition  of  the  milk  at  the  time 
that  the  sample  was  taken.  The  bacterial  count  is  a  check  upon 
the  scoring  system ;  while  the  scoring  will  reveal  the  probable 
sources  of  the  bacteria  when  the  count  is  high.  The  most  prac- 
tical system  of  grading  milk  is  that  founded  upon  a  combination 
of  the  score  card  and  the  bacterial  count. 

It  often  happens  that  dirty  milk  containing  many  bacteria 
is  produced  in  a  dairy  which  has  a  high  score,  and  that  a  high 
grade  of  milk  is  produced  in  one  having  a  low  score.  A  person 
without  a  natural  tendency  to  be  clean  and  careful  will  produce 
dirty  milk  even  when  his  equipment  and  methods  seem  to  be 
perfect.  On  the  other  hand,  a  person  with  cleanly  instincts  and 
habits  will  produce  clean  milk  amid  unfavorable  surroundings. 
Cleanliness  in  producing  wholesome  milk  is  like  surgical  clean- 
liness. A  health  officer  must  take  into  consideration  a  dairy- 
man's personal  equation  of  cleanliness  in  judging  the  whole- 
someness  of  his  milk. 

Milk  is  usually  graded  as  A,  B,  or  C,  and  each  of  these  grades 
is  divided  into  raw  and  pasteurized,  making  six  in  all.  The 
standards  differ  in  various  locaHties.  Those  required  by  the 
sanitary  code  of  New  York  State  are  shown  by  the  following 
table : 


MILK 


361 


Maximum    bac- 
Cows.    Test  terial  count  per  Time  of 

Grade.  required.  cubic  centimeter.  Score  card.  delivery. 

Grade  A,  raw.  Tuberculin         60,000.  Equip 25    36  hours. 

test  neg.                                   Methods..  .50 
Total 75~ 

Grade  A,  pasteur-    Phys.  exam.      200,000      be-.    Equip 25    36 hours  after 

ized.  neg.  fore       pas-     Methods.  .43        pjasteur- 

teurizing  izing. 

and   30,000     Total ....  ."68" 
afterward. 

Grade  B,  raw.  Phys.  exam.       200,000.  Equip 23    36  hours. 

neg.                                            Methods...  37 
Total ."60" 

Grade  B,  pasteur-     Phys.  exam.       150,000      be-     Equip 23  48  hours  after 

ized.                             neg.                     fore       and  Methods...  35  pasteur- 

100,000  af-                      izihg. 

ter.  Total 58 

Grade  C,  raw.  None.  No  limit.  Total 40    48  hours. 

Grade  C,  pasteur-    None.  No  limit.  Total 40    48  hours  after 

ized.  pasteur- 

izing. 

Grade  A  milk  raw  and  Grade  A  pasteurized  are  produced 
under  the  most  approved  methods  of  care  and  cleanliness,  and 
are  the  only  two  grades  that  are  up  to  the  standard  of  cleanli- 
ness and  wholesomeness  that  may  reasonably  be  required  of 
dairymen  under  modern  conditions.  Two  difficulties  in  the  way 
of  requiring  that  all  milk  shall  be  Grade  A  are  the  cost  of  produc- 
tion and  the  lack  of  dairymen  who  have  sufficient  skill  and 
inclination  to  produce  enough  first-class  milk  to  supply  the 
market.  While  the  farmers  and  dairymen  with  business  ability 
can  produce  Grade  A  milk  at  a  profit  under  present  conditions 
and  prices,  the  smaller  and  less  skilled  producers  are  less  able 
to  do  so.  We  are,  therefore,  confronted  with  the  necessity 
either  of  accepting  a  lower  grade  of  milk  or  of  producing  a  milk 
famine  and  upsetting  the  whole  economic  system  of  farmers. 

Grade  B  milk  is  of  fair  quality,  and  if  it  is  pasteurized  with 
care,  it  will  be  free  from  the  germs  of  human  diseases.  It  is  the 
lowest  grade  of  milk  that  may  be  safely  allowed  on  sale.  If  a 
board  of  health  should  forbid  the  sale  of  milk  that  has  a  lower 
grade,  the  order  would  promote  the  healthfulness  of  a  community, 
and  would  not  usually  interfere  with  economic  conditions. 

Grade  C  milk  is  that  which  is  produced  under  few  or  no 
restrictions.  The  only  use  to  which  it  may  safely  be  put  is  that 
of  cooking. 

Certified  Milk. — In  addition  to  the  six  usual  grades  of  milk 
the  sanitary  codes  of  New  York  State  and  New  York  City  recog- 
nize a  grade  called  certified  milk,  or  Grade  A  Certified.     This 


362  THE   HEALTH   OFFICER 

milk  is  produced  with  the  greatest  care  that  is  possible  under 
commercial  conditions,  and  its  purity,  freshness,  and  whole- 
someness  are  certified  by  a  responsible  commission  appointed  by 
a  county  medical  society  which  is  under  and  chartered  by  the 
State  ]\Iedical  Society.  A  bacterial  examination  of  the  milk  is 
made  almost  daily,  the  dairies  are  scored  at  frequent  inter\-als, 
and  the  cows  are  tested  with  tuberculin  at  least  once  a  year 
and  all  suspicious  animals  are  removed.  The  maximum  bac- 
terial count  allowed  is  10,000  per  cubic  centimeter.  Certified 
milk  is  as  pure  and  wholesome  as  any  unpasteurized  milk  can 
be.  If  there  is  a  lingering  doubt  regarding  its  wholesomeness, 
pasteurization  will  render  it  safe  beyond  reasonable  doubt. 

Permits  to  Sell  Milk. — IMilk  influences  public  health  so 
directly  that  the  people  demand  that  the  department  of  health 
shall  supervise  its  production  and  distribution.  The  object  of 
the  supervision  is  not  to  restrict  the  output  of  milk,  but  to 
improve  its  quality.  Inspectors  and  health  officers  are  not 
expected  to  try  to  put  any  milkman  out  of  business,  but  to  help 
him  to  increase  the  quahty  and  amount  of  his  product.  Many 
people  who  fear  to  use  milk  would  buy  it  if  they  were  assured  of 
its  quality  and  wholesomeness.  The  intelligent  supervision  of 
all  milk-supplies  is  becoming  more  and  more  a  duty  which  is 
expected  from  health  officers.  The  Sanitary  Code  of  New^  York 
State  requires  that  every  person  selling  milk  shall  obtain  a  per- 
mit annually  from  a  local  health  officer,  and  that  no  permit 
shall  be  issued  until  the  dairy  has  been  found  to  score  at 
least  40  per  cent,  within  six  months.  This  is  a  low  score,  but 
the  local  health  board  of  any  municipality  may  raise  the  re- 
quirements. It  is  necessary  that  every  health  officer  shall 
know  how  to  use  a  score  card,  and  how  to  interpret  the  items 
of  the  score. 

Using  a  Score  Card. — A  score  card  is  divided  into  two  parts 
— equipment  and  methods.  The  total  of  the  items  of  perfect 
score  for  equipment  is  40,  and  for  methods  it  is  60.  The  equip- 
ment is  of  less  importance  than  the  way  it  is  used,  and  a  health 
officer  will  consider  its  usefulness  and  practicability  rather  than 
its  cost.  It  is  not  necessary  that  a  farmer  build  an  expensive 
barn  and  install  complicated  machinery  in  order  to  produce 
wholesome  milk.  The  quality  of  milk  is  aff'ected  by  the  floor 
plan  and  location  of  the  buildings  much  more  than  by  the 
amount  of  money  spent  on  them.  It  is  far  more  important  that 
a  stable  be  kept  clean  than  that  it  be  made  out  of  new  and  ex- 
pensive materials.  The  standards  of  construction  and  repair 
that  yield  the  most  efficient  and  economic  results  are  those  which 
a  farmer  of  ordinary  means  and  intelligence  would  approve.     It 


MILK  363 

is  the  duty  of  the  health  officer  to  consider  the  interests  of  the 
producer  as  well  as  those  of  the  consumer. 

Scoring  a  dairy  is  an  official  act,  and  the  health  officer,  or  his 
representative,  must  personally  judge  each  item  on  the  card  by 
an  actual  observation.  It  is  best  that  the  scoring  be  done  in 
the  presence  of  the  dairyman,  both  for  his  instruction  and  also 
to  prevent  disputes. 

The  health  officer  can  score  the  equipment  accurately,  for 
it  is  permanent  and  can  readily  be  inspected.  But  he  may  have 
some  difficulty  in  seeing  the  workmen  perform  every  process, 
and  he  cannot  be  sure  that  they  will  always  be  as  careful  as  they 
are  while  he  is  looking  at  them.  This  variability  and  the  uncer- 
tainty in  judging  methods  as  compared  with  equipment  must  be 
considered  in  the  interpretation  of  a  score  card. 

When  a  health  officer  starts  to  score  a  dairy,  it  is  a  good  plan 
for  him  to  give  the  dairyman  a  copy  of  the  score  card,  and  to 
score  the  items  in  the  order  in  which  they  appear  on  the  card, 
and  to  explain  each  point  and  its  bearing  on  the  cleanliness  and 
wholesomeness  of  the  milk.  The  points  on  the  score  care  will 
be  discussed  in  the  remainder  of  the  chapter. 

The  Cows. — The  first  item  on  the  score  card  relates  to  the 
health  of  the  cows.  A  health  officer  will  judge  their  health  by 
three  methods:  1,  an  inspection;  2,  a  physical  examination;  and 
3,  the  tuberculin  test. 

A  mere  inspection  of  the  herd  has  a  considerable  value,  for 
if  a  cow  becomes  sick,  she  usually  shows  the  illness  by  her 
appearance  and  actions.  The  presence  of  a  cow  that  appears  to 
be  unhealthy  is  sufficient  ground  for  a  health  officer  to  require 
the  isolation  of  the  animal  until  the  nature  of  the  disease  can 
be  determined.  An  unhealthy  animal  has  no  place  in  a  dairy 
herd. 

A  physical  examination  of  the  cows  such  as  health  officers 
can  make  will  have  a  considerable  value  in  determining  their 
health.     A  simple , routine  examination  of  a  cow  is  as  follows: 

1.  Note  its  general  appearance,  fatness,  sleekness,  and 
attitude. 

2.  Note  the  presence  of  visible  sores,  swellings,  or  other 
defects. 

3.  Note  the  manner  of  breathing  and  the  presence  of  a 
cough. 

4.  Note  the  elasticity  of  the  skin  by  pinching  and  stretching 
it.     The  skin  of  a  healthy  animal  is  soft  and  elastic. 

5.  Feel  under  the  jaw  for  enlarged  glands. 

6.  Feel  the  udder  for  lumps  and  other  evidences  of  inflam- 
mation. 


364  THE  HEALTH   OFFICER 

7.  Draw  a  few  streams  of  milk  from  each  teat  into  the  hand 
and  note  any  abnormal  appearance. 

8.  Note  the  presence  of  diarrhea  or  abnormal  discharges. 
The  tuberculin  reaction  is  the  most  valuable  health  test,  for 

tuberculosis  is  the  most  common  bovine  disease  with  which  a 
dair\man  has  to  deal,  and  the  reaction  will  reveal  it  in  its  in- 
cipiency  (page  353). 

The  food  and  drink  of  cows  has  a  direct  effect  on  their  health 
and  on  the  wholesomeness  of  their  milk.  The  New  York  State 
Agricultural  Law,  Section  30,  defines  one  form  of  adulterated 
milk  to  be  that  "drawn  from  animals  fed  on  distillery  waste  or 
any  substance  in  a  state  of  fermentation  or  putrefaction,  or  on 
any  unhealthy  food,"  but  the  next  section  exempts  ensilage. 
Water  containing  the  specific  bacteria  of  bovine  diseases,  espe- 
cially those  of  the  colon  bacillus  type,  is  often  the  cause  of  in- 
testinal diseases  among  cows.  A  pure  water-supply  for  a  dairy 
herd  is  as  important  as  one  for  human  beings.  A  health  ofiicer 
may  properly  condemn  a  dairy  water-supply  that  is  polluted  with 
the  discharges  of  cattle. 

Stables. — Housing  conditions  affect  the  health  and  milk 
production  of  cows  in  about  the  same  way  that  they  do  the 
health  and  working  efficiency  of  persons.  A  dark,  tumble-down 
house  is  as  bad  for  a  cow  as  for  a  human  being,  and  milk  pro- 
duced in  such  a  house  is  likely  to  be  unprofitable  to  the  producer 
and  unwholesome  to  the  consumer. 

A  health  officer  will  consider  the  drainage  of  a  stable  and 
yard.  When  the  manure  is  removed  from  the  yard,  some  of 
the  earth  is  removed  with  it  until  a  depression  is  often  made 
which  becomes  filled  with  water  after  each  rain.  A  health  offi- 
cer will  note  whether  or  not  the  yard  is  kept  graded,  and  pro- 
vision made  for  carrying  oft"  the  surface  water. 

The  health  officer  will  look  for  contaminating  surroundings 
near  the  stable,  such  as  privies,  pig-pens,  hen-roosts,  manure 
piles,  and  garbage  heaps.  All  these  things  may  be  sources  of 
contamination  on  account  of  their  drainage,  dust,  and  odors,  and 
also  because  they  may  be  the  breeding-places  for  flies  and  ver- 
min. A  horse  stable  in  the  same  stable  with  cows,  or  directly 
connected  with  the  cow  stable,  is  to  be  condemned. 

There  is  no  standard  material  for  stable  floors.  Earth 
becomes  muddy  or  dusty,  and  will  be  scored  zero.  Wood  may 
be  scored  perfect  if  it  is  kept  in  good  repair.  Cement  is  the 
most  sanitary  material,  and  is  also  usually  the  cheapest. 

Sanitary  stables  are  now  built  on  the  standard  plan  of  open 
interior  construction  with  as  few  partitions  and  obstructions  as 
possible.     The  floor  is  of  smooth  cement  with  a  shallow  trough 


MILK  365 

in  front  of  the  cows  for  a  manger,  and  a  deep,  square  gutter 
behind  them  to  receive  their  droppings.  There  are  no  parti- 
tions between  the  cows,  and  the  only  raised  structure  above  the 
floor  is  a  row  of  stanchions  in  which  the  cows  are  held  or  tied. 
Each  stanchion  is  hung  on  swivels  so  that  a  cow  may  lie  down 
or  turn  her  head  freely,  and  yet  it  confines  her  so  closely 
that  she  cannot  soil  the  bedding  and  platform  on  which  she 
stands. 

It  is  essential  that  the  side  walls  and  ceihngs  be  smooth  and 
tight,  and  that  there  be  no  projecting  ledges  to  catch  dirt.  A 
hay  loft  above  the  cows  with  poles  or  loose  boards  for  a  floor 
will  be  scored  zero,  for  it  allows  quantities  of  dust  and  dirt  to 
fall  into  the  stable. 

The  reasons  for  lighting  a  stable  are  the  same  as  those  for 
lighting  a  human  dwelling.  A  health  officer  is  expected  to  meas- 
ure the  windows  and  the  size  of  the  stable,  and  to  estimate  the 
amount  of  light  and  space  per  cow  with  a  considerable  degree  of 
accuracy. 

Bedding  is  necessary  for  the  comfort  and  cleanliness  of  the 
cows.  The  best  bedding  is  probably  sawdust  or  wood  shavings 
because  of  their  freedom  from  dust.  Moldy  hay  and  dried 
manure  are  to  be  condemned  for  bedding. 

Ventilation  and  heating  are  to  be  considered  together  and  in 
connection  with  the  window  space.  The  old-fashioned  barn 
with  open  cracks  between  the  boards  was  often  ventilated  too 
much,  and  in  winter  was  as  cold  as  the  outside  air.  It  is  not 
economic  to  use  feed  in  order  to  keep  a  cow  warm  when  a  stable 
may  readily  be  built  and  ventilated  in  such  a  way  that  its 
temperature  remains  at  about  50°  F.,  even  on  cold  nights.  A 
new  stable  with  tight  sides  of  matched  boards  and  few  windows 
is  likely  to  be  poorly  ventilated,  and  too  warm  and  close  for 
comfort.  If  a  health  officer  finds  the  sides  of  a  stable  to  be  w^et 
with  condensed  moisture,  he  may  be  sure  that  the  stable  is 
poorly  ventilated.  An  excellent  method  of  securing  ventilation 
without  cold  drafts  is  to  remove  some  of  the  window  sashes  and 
tack  muslin  over  the  openings. 

A  standard  space  of  500  cubic  feet  per  cow  is  found  to  give 
the  most  satisfactory  balance  between  ventilation  and  tempera- 
ture. If  the  space  is  larger,  the  temperature  will  be  too  low,  and 
if  it  is  smaller,  the  air  will  either  be  too  close  or  cold  drafts  will 
be  formed. 

A  system  of  ventilating  flues  with  separate  intakes  and 
outlets  will  work  well  provided  the  sides  of  the  building  are 
tight  and  the  dairymen  use  good  judgment  in  operating  the 
flues. 


366  THE   HEALTH   OFFICER 

Utensils. — A  health  officer  will  give  particular  attention  to 
the  dairy  utensils,  for  they  have  a  great  effect  on  the  cleanliness 
and  wholesomeness  of  the  milk.  It  is  iniportant  that  the  inner 
surfaces  of  the  pails  and  cans  be  smooth  and  polished,  and  free 
from  dust  and  rust,  and  from  open  seams  in  which  dirt  and 
dried  milk  may  collect. 

An  abundance  of  water  and  facilities  for  heating  it  are  neces- 
sary in  cleansing  the  pails  and  bottles.  If  a  health  officer  finds 
that  a  dair^Tiian  has  only  two  wash-tubs  for  washing  a  hun- 
dred milk  bottles  daily,  and  has  only  an  oil  stove  or  two  for 
heating  the  water,  he  may  properly  score  the  dairy  zero  and 
condemn  the  whole  outfit.  If  one  hundred  or  more  bottles  are 
to  be  washed  daily,  it  is  necessary  that  a  boiler  be  installed  for 
heating  the  water  with  steam,  and  keeping  it  hot  during  the 
whole  process. 

A  small-top  milking  pail  is  one  whose  opening  measures  8 
inches  or  less.  The  large  score  of  5  is  assigned  to  this  kind  of 
pail,  for  only  a  small  amount  of  dirt  will  fall  through  the  small 
opening.  Experience  shows  that  the  change  from  a  large-top 
pail  to  a  small-top  one  is  followed  by  a  great  reduction  in  the 
number  of  bacteria  in  the  milk.  One  of  the  best  pieces  of 
advice  that  a  health  officer  can  give  to  a  dairyman  is  to  use  a 
small-top  milking  pail. 

A  milk  cooler  is  a  most  valuable  utensil  if  it  is  properly 
handled.  It  may  be  a  source  of  danger  if  it  is  unclean,  or  out  of 
repair,  or  exposed  to  dust  and  flies.  The  ordinary  type  of  cooler 
is  one  in  which  the  milk  flows  in  a  thin  film  over  a  large  can  filled 
with  cold  water  or  ice.  A  great  objection  to  it  is  that  it  is 
exposed  to  dust  and  flies.  A  better  form  of  cooler  is  a  thin, 
flat  one  which  may  be  enclosed. 

Dairymen  talk  a  great  deal  about  what  they  call  the  animal 
heat  of  the  milk,  and  the  supposed  danger  if  it  is  retained.  The 
health  officer  will  often  find  it  necessary  to  explain  that  animal 
heat  is  the  same  as  any  other  heat,  and  that  the  objectionable 
conditions  of  animal  origin  which  a  cooler  removes  from  milk 
are  the  tastes  and  odors.  The  health  officer  will  often  need  to 
instruct  the  dairyman  in  the  proper  use  of  a  cooler. 

The  cleanliness  of  the  milkman's  clothes  may  affect  the  qual- 
ity of  the  milk,  especially  if  they  are  covered  with  dust  and 
loose  dirt  which  may  fall  into  the  milk.  A  health  officer,  for 
example,  will  advise  a  farmer  coming  from  a  dusty  field  to  put 
on  a  clean  coat  and  overalls  before  he  milks.  The  milkers  on 
farms  producing  certified  milk  are  required  to  put  on  freshly 
laundered  suits  at  each  milking. 

Milk  Room  and  Milk  House. — A  health  officer  will  condemn 


MILK  367 

a  milk  room  or  milk  house  if  it  is  located  near  a  privy  or  manure 
pile,  or  beside  a  dusty  road,  or  in  any  other  place  where  dust  or 
dirt  or  odors  are  likely  to  contaminate  the  milk.  If  a  privy  is 
used  on  a  dairy  farm,  a  health  officer  may  well  advise  that  it 
be  fly-tight,  and  have  the  pail  system  of  disposal  of  excreta. 

A  health  ofhcer  will  score  a  milk  room  zero  if  its  floors,  walls, 
and  ceilings  are  rough  and  out  of  repair,  or  if  it  is  not  well  lighted, 
ventilated,  and  screened  from  flies.  He  will  give  credit  if  the 
room  for  receiving  and  washing  dirty  utensils  is  separated  from 
the  room  in  which  clean  utensils  are  stored  and  milk  is  handled. 
If  the  milk  room  is  located  in  the  cow  barn,  the  health  officer 
will  require  that  it  either  be  completely  separated  from  the 
stable,  or  be  entered  through  an  intermediate  room  in  order  to 
exclude  the  dirt  and  odors  from  the  stable. 

Cleanliness. — The  second  column  of  the  score  card  relates 
to  the  manner  in  which  a  dairyman  uses  his  equipment.  The 
essential  point  which  a  health  officer  will  have  in  mind  is  clean- 
liness. While  it  is  possible  to  produce  clean  milk  with  a  dilapi- 
dated equipment,  yet  a  dairyman  who  has  such  an  equipment 
will  be  careless  in  the  way  he  uses  it;  and,  on  the  other  hand, 
a  dairyman  who  is  careful  and  clean  will  keep  his  equipment 
in  good  repair.  The  condition  of  the  equipment  is  an  excel- 
lent indication  of  the  methods  which  a  dairyman  habitually 
follows. 

Cows. — Cleanliness  of  the  cows  is  given  one  of  the  highest  of 
aU  the  ratings  on  the  score  card.  If  the  cows  are  dirty,  some 
of  the  dirt  is  sure  to  fall  into  the  milk-pail  during  milking.  It 
is  impossible  for  a  cow  to  keep  herself  clean  in  an  ordinary 
stable.  Dried  manure  and  loose  hair  in  a  cow's  flanks  are 
indications  that  the  dairyman  does  not  clean  the  animal  regu- 
larly. A  good  dairyman  will  curry  the  coats  of  the  cows  daily, 
and  will  clip  the  long  hairs  from  the  flanks  and  udders  on  the 
side  on  which  the  milker  sits. 

Stables.— The  total  rating  for  the  cleanliness  of  the  stable 
and  barnyard  is  large,  but  it  is  subdivided  into  ratings  of  the 
individual  parts,  each  of  which  a  health  officer  will  note  in  his 
inspections.  The  drainage  of  the  barnyard  and  the  removal  of 
the  manure  daily  have  a  great  effect  on  the  cleanhness  of  the 
cows  and  on  the  bacterial  count  of  the  milk. 

The  cleanliness  of  the  stable  and  the  purity  of  the  air  at 
milking  times  are  of  greater  importance  than  their  condition  at 
other  times.  A  health  officer  will  require  that  currying  the 
cows,  feeding  hay,  and  preparing  the  bedding  shall  be  done 
after  milking  in  order  to  avoid  dust  in  the  air  during  milking 
time. 


368  THE  HEALTH   OFFICER 

Milk  Room. — The  cleanliness  of  the  milk  room  is  of  greater 
importance  than  would  seem  to  be  indicated  by  its  low  rating, 
but  a  dair\Tnan  does  not  deserve  credit  for  being  decently  clean. 
A  health  ofhcer  may  properly  condemn  a  milk  room  if  it  is  not 
kept  up  to  the  modern  standard  of  cleanliness  of  a  kitchen. 

Ulcnsils. — Much  of  the  bad  taste  of  milk  comes  from  bac- 
teria growing  in  decomposing  milk  that  is  left  in  the  corners  and 
seams  of  the  utensils.  The  minute  remnants  of  milk  that  re- 
main after  careful  cleansing  will  provide  food  for  an  abundant 
growth  of  bacteria  unless  the  bacteria  are  killed.  The  cleanli- 
ness and  sanitary  condition  of  the  utensils  will  depend  largely 
upon  the  quantity  of  boiling  water  or  steam  that  is  used  in  wash- 
ing them.  A  temperature  of  at  least  180°  F.  is  necessary  in 
order  to  sterilize  the  utensils.  A  tea-kettle  full  of  boiling  water 
poured  into  a  milk  can  may  be  merely  warm  after  it  has  been 
in  the  can  for  a  few  seconds. 

A  test  of  the  efficiency  of  the  processes  of  washing  and  steril- 
ization is  the  odor  of  the  utensil  after  it  has  been  closed  for  some 
time.  Cover  a  milk  can,  or  pail,  or  bottle  for  an  hour,  and  then 
open  it  and  test  its  odor.  If  the  odor  is  unpleasant,  the  milk 
that  is  put  into  the  utensil  will  acquire  a  similar  odor  and  an 
unpleasant  taste.  Dairj-men  frequently  leave  the  covers  off  the 
washed  cans  in  order  to  avoid  the  unpleasant  odor  which  they 
suppose  must  necessarily  develop  in  a  closed  container.  A 
health  officer  can  demonstrate  the  effect  of  sterilization  on  the 
odor  by  washing  a  container  in  warm  water  and  boiling  a  sim- 
ilar one,  and  then  carrying  out  the  odor  test  on  both. 

An  accurate  test  of  the  sterilization  of  the  utensils  is  afforded 
by  a  bacteriologic  examination  of  the  drops  of  water  that  are 
left  in  the  cans  after  washing.  Samples  for  a  bacteriologic 
examination  may  be  taken  by  shaking  a  small  quantity  of  cold, 
boiled  water  in  the  container  and  sending  a  sample  to  the  labora- 
tory. Samples  may  also  be  taken  by  rubbing  a  swab  moistened 
with  sterile  water  over  the  inner  surface  of  the  container  and 
inoculating  a  culture-tube. 

Milking. — Cleanliness  of  milking  is  given  the  highest  of  all 
the  ratings  on  the  score  card,  for  the  time  w^hen  milk  is  the 
most  likely  to  be  contaminated  is  during  milking.  The  neces- 
sary movements  of  the  milkers'  hands  and  of  the  udders  ^vill 
dislodge  epithelial  scales  if  nothing  else.  While  it  is  sometimes 
possible  to  draw  a  few  streams  of  milk  in  a  sterile  condition,  yet 
milk  always  contains  bacteria  when  it  is  drawn  into  a  pail  in 
which  it  remains  under  a  cow  for  a  few  seconds.  But  the 
number  of  bacteria  may  be  kept  extremely  low  by  careful  meth- 
ods of  cleanliness  during  milking. 


MILK  369 

Clean  hands  are  as  necessary  for  a  milker  as  for  a  cook  who 
handles  the  milk  in  the  kitchen.  A  dairyman  who  wishes  to 
produce  a  high  grade  of  milk  will  require  the  milkers  to  wash 
their  hands  before  milking  each  cow.  Some  milkers  have  a 
habit  of  wetting  their  hands  with  milk.  This  is  an  uncleanly 
practice,  for  it  is  almost  impossible  to  milk  with  wet  hands  with- 
out dropping  some  of  the  soiled  liquid  into  the  pail. 

If  the  udders  and  flanks  of  the  cows  are  clean,  there  will  be 
little  or  no  dirt  to  fall  into  the  pail.  Three  methods  are  in  com- 
mon use  for  cleaning  them:  first,  washing  them  and  drying  them 
with  a  clean  towel;  second,  wiping  them  with  a  damp  cloth; 
and  third,  wiping  them  with  a  dry  cloth.  Cleaning  with  a  dry 
cloth  may  raise  dust  and  do  more  harm  than  good.  A  health 
officer  will  inquire  into  the  cleanliness  of  the  cloths  used  in 
cleaning  the  udders. 

Handling  the  Milk. — Dairymen  who  are  careless  or  lazy  fre- 
quently pour  the  milk  into  an  open  can  which  stands  in  the  barn 
where  it  collects  dirt  and  absorbs  odors.  A  health  officer  may 
properly  require  the  milkers  to  remove  the  milk  to  a  protected 
place  immediately  after  milking  each  cow,  and  that  those  who 
work  in  the  stable  shall  change  at  least  their  shoes  if  they  handle 
the  milk  in  the  milk  room. 

Cooling  Milk. — The  only  allowable  means  of  preventing  the 
growth  and  multiplication  of  bacteria  in  milk  is  coldness.  The 
degree  of  temperature  that  is  necessary  will  depend  largely  on 
the  length  of  time  that  the  milk  is  to  be  kept.  The  milk  of 
New  York  City  is  at  least  three  days  old  when  it  reaches  the 
customers,  and  a  temperature  of  40°  F.  is  required  in  order  to 
preserve  it.  Milk  need  not  be  cooled  at  all  if  it  is  sold  by  a 
farmer  from  the  kitchen  door  to  a  neighbor  for  immediate  use. 
A  health  officer  usually  deals  with  milk  that  reaches  the  cus- 
tomer within  twenty-four  hours  after  it  is  drawn  from  the  cow. 
A  temperature  between  50°  and  60°  F.  is  usually  satisfactory  for 
this  milk. 

The  usual  method  of  cooling  milk  in  rural  districts  is  to  set 
the  cans  in  freshly  drawn  water  from  a  spring  or  well,  or  into  the 
spring  itself.  The  water  usually  has  a  temperature  between 
50°  and  55°  F.  If  this  method  of  coohng  is  used  a  health  officer 
may  know  that  the  milk  has  not  been  cooled  below  about  55°  F. 

There  is  often  difficulty  in  keeping  milk  at  a  low  tempera- 
ture during  transportation  when  its  quantity  is  small.  A  health 
board  may  remedy  this  condition  somewhat  by  passing  an  ordi- 
nance requiring  that  milk  be  delivered  within  a  certain  period 
unless  it  is  kept  below  a  specified  temperature.  A  health  board 
may  also  pass  an  ordinance  specifying  the  maximum  tempera- 

24 


370  THE  HEALTH    OFFICER 

ture  of  milk  which  may  be  allowed  on  deUvery  wagons.  A 
health  officer  has  the  right  to  take  the  temperature  of  milk  in 
dairies  and  on  delivery  wagons  in  order  to  make  a  proper  scoring. 
Some  communities  require  a  health  officer  to  score  a  milk 
producer  and  issue  a  permit  even  when  a  farmer  keeps  only  one 
cow  and  sells  only  a  few  quarts  from  his  kitchen  door.  A  health 
ofticer  in  such  a  case  would  consider  the  kitchen  to  be  the  milk 
room,  the  kitchen  pump  to  be  the  water-supply,  and  the  kitchen 
stove  to  afford  the  facilities  for  heating  the  water. 


CHAPTER  XXXIII 

FOOD  SANITATION 

Milk  is  a  food  that  is  in  a  class  by  itself,  owing  to  its  lia- 
bility to  undergo  changes,  develop  unwholesome  products,  and 
become  a  spreader  of  disease  germs.  It  may  endanger  public 
health  to  such  an  extent  that  the  supervision  and  control  of  its 
production  and  distribution  is  exercised  by  boards  of  health 
without  question.  But  the  same  kinds  of  changes  and  infections 
that  affect  milk  may  affect  other  foods  also.  Various  depart- 
ments of  national  and  state  governments  are  undertaking  cer- 
tain phases  of  food  supervision  largely  on  economic  grounds; 
and  the  departments  of  health  of  the  larger  cities  are  extending 
the  work  for  sanitary  reasons.  The  control  of  the  sanitary  con- 
ditions of  foods,  drinks,  and  confectionery  that  are  offered  for 
sale  is  under  the  jurisdiction  of  a  local  board  of  health,  and  the 
details  of  the  supervision  are  within  the  scope  of  the  activities 
of  health  officers  and  public  health  nurses.  The  word  "food" 
is  used  in  the  general  sense  to  include  drinks,  confectionery,  and 
other  substances  which  are  ordinarily  taken  into  the  stomach. 

The  conditions  which  may  affect  the  wholesomeness  of  food 
may  be  considered  under  four  headings:  1,  the  state  of  the  food 
itself;  2,  the  methods  of  preserving  the  food;  3,  the  health  of 
persons  who  handle  the  food;  and  4,  the  sanitation  of  the  places 
in  which  foods  and  drinks  are  sold. 

The  conditions  of  food  itself  which  may  affect  health  are 
(1)  its  purity  or  freedom  from  adulteration,  (2)  its  state  of  fresh- 
ness or  decomposition,  and  (3)  the  presence  of  poisons  or  disease 
germs. 

Adulteration. — If  a  food  has  a  composition  different  from  that 
which  it  is  purported  to  have,  it  is  called  an  adulterated  or 
sophisticated  food.  The  conditions  which  are  considered  to  be 
adulterations  or  sophistications  are  set  forth  in  the  Federal 
Food  and  Drugs  Act  of  June  30,  1906,  and  are  as  follows: 

1.  Foods  containing  substances  which  are  added  in  order  to 
reduce  their  quality  or  strength,  as,  for  example,  watered  milk. 

2.  Foods  in  which  cheap  substances  are  substituted  for  more 
expensive  articles,  as,  for  example,  cottonseed  oil  for  oHve  oil. 

3.  The  meat  of  diseased  animals,  or  foods  containing  filthy, 
decomposed,  or  putrid  substances  or  products,  as,  for  example, 

371 


372  THE  HEALTH   OFFICER 

oysters  contaminated  with  sewage,  and  eggs  on  the  verge  of 
decay. 

4.  Foods  from  which  any  valuable  constituents  have  been 
removed,  as,  for  example,  skimmed  milk.  But  the  sale  of  such 
foods  is  permitted  provided  their  actual  nature  or  composition 
is  stated  on  the  labels  or  is  told  to  the  buyers. 

5.  Foods  colored  or  otherwise  treated  in  order  to  disguise 
damage  or  inferiorit}',  as,  for  example,  old  meat  colored  red  to 
resemble  fresh  meat. 

The  principal  ground  on  which  adulterations  are  condemned 
is  that  of  fraud.  A  health  department  has  no  jurisdiction  over 
adulterations  on  the  ground  of  fraud  alone,  unless  it  is  specifically 
authorized  by  law  to  act;  but  it  may  properly  take  action  when 
the  adulterations  have  an  effect  on  public  health. 

Freshness. — Many  foods  readily  undergo  changes  in  their 
physical  state  which  render  them  undesirable  as  food  without 
directly  affecting  their  wholesomeness.  Examples  of  loss  of 
freshness  are  the  wilting  of  vegetables,  the  softening  of  hard 
crackers  during  moist  weather,  and  the  lumpiness  of  old  corn- 
meal  due  to  the  action  of  the  oil  of  the  corn.  A  department  of 
health  has  little  or  nothing  to  do  with  this  group  of  foods. 

Decomposition. — The  word  "freshness"  is  also  applied  to  the 
chemical  state  of  food.  A  chemical  change  in  food  is  usually 
called  decomposition,  and  is  nearly  always  caused  by  the  growth 
of  micro-organisms  in  the  food.  Decomposition  is  not  neces- 
sarily a  harmful  process,  and  it  is  often  applied  in  the  manu- 
facture of  foods.  Butter,  cheese,  and  other  dairy  products  are 
made  with  the  aid  of  bacteria;  bread  is  made  light  by  the  growth 
of  yeast  plants;  sour  bread  is  made  by  the  action  of  yeast  and 
bacteria;  sauer  kraut  and  pickles  are  products  of  bacterial  action; 
and  meat  is  improved  in  texture  and  flavor  by  the  bacterial 
growth  which  takes  place  while  it  is  hung  in  a  cool  room  for  a 
few  days. 

The  processes  of  decomposition  in  foods  may  be  divided  into 
two  main  groups:  1,  fermentation,  or  the  change  of  sugars  and 
starches  to  acids  and  gases,  such  as  lactic  acid  in  milk;  and  2, 
putrefaction,  or  the  change  of  proteins  to  alkaline  products, 
many  of  which  are  offensive  to  the  senses  and  poisonous.  The 
products  of  the  fermentation  of  sugars  and  starches  are  seldom 
harmful  in  themselves,  but  they  are  often  associated  with  prod- 
ucts of  the  putrefaction  of  proteins.  When  souring  takes  place 
in  a  food  in  which  the  production  of  acids  is  not  a  normal 
process,  it  may  properly  be  considered  to  be  an  indication  of 
unwholesomeness. 

The  ordinary  decomposition  or  putrefaction  of  proteins  gives 


FOOD    SANITATION  373 

rise  to  a  class  of  poisonous  products  called  ptomains.  The 
usual  symptoms  of  poisoning  by  the  ptomains  of  decomposed 
food  are  abdominal  pain,  vomiting,  diarrhea,  fever,  and  weak- 
ness, and  develop  within  a  few  hours  or  a  day  after  the  food  has 
been  eaten.  The  products  of  ordinary  decomposition  are  not 
usually  poisonous  when  their  offensive  odors  and  tastes  first 
begin  to  be  apparent,  or  when  the  process  of  decomposition  is 
far  advanced  toward  the  final  end-products.  They  are  more 
frequently  poisonous  during  the  intermediate  stages  of  decom- 
position, but  their  offensiveness  is  then  so  apparent  that  one 
instinctively  shuns  the  food.  A  trace  of  the  peculiar  odors  and 
tastes  which  are  associated  with  putrefaction  may  be  considered 
to  be  danger  signs  of  approaching  unwholesomeness,  and  a  food 
in  which  they  are  present  may  properly  be  condemned. 

Specific  Bacteria  of  Food  Poisoning. — The  severe  forms  of 
food  poisoning  are  usually  caused  by  specific  bacteria  which 
are  not  usually  present  in  and  around  food,  but  which  are 
transmitted  by  the  contact  of  one  parcel  of  food  with  another, 
or  with  a  diseased  person  or  animal.  Food  containing  these 
organisms  may  be  considered  to  be  infected  in  the  same  sense 
that  a  culture-tube  is  infected  when  it  is  inoculated  with  diph- 
theria bacilli;  or  that  a  person  with  typhoid  fever  is  infected 
with  typhoid  bacilli. 

The  specific  bacteria  of  food  poisoning  belong  to  the  para- 
typhoid group,  and  consist  of  many  varieties,  some  of  which  are 
peculiar  to  human  beings  only,  while  others  are  peculiar  to  cat- 
tle, or  to  pigs,  rats,  mice,  or  other  lower  animals.  Two  char- 
acteristics which  are  common  to  all  varieties  of  the  bacteria 
are  (1)  the  production  of  toxins  and  (2)  the  ability  to  grow  in 
meat  and  other  foods.  The  symptoms  of  poisoning  in  man  may 
be  caused  either  by  the  toxins  that  developed  in  the  food  before 
it  was  eaten,  or  by  the  growth  of  the  bacteria  themselves  after 
they  have  been  introduced  into  the  human  body.  The  bac- 
teria may  be  present  in  an  animal  that  was  sick  before  it  was 
killed,  or  they  may  be  introduced  into  meat  or  other  food  by  a 
human  carrier  or  by  contact  with  infected  meat,  or  the  infected 
dirt  of  slaughter  houses  or  butcher  shops.  The  bacteria  which 
are  peculiar  to  lower  animals  seldom  grow  in  human-  beings, 
but  their  toxins  may  produce  the  abdominal  symptoms  of  food 
poisoning.  The  bacteria  which  are  peculiar  to  mankind  pro- 
duce paratyphoid  fever  when  they  are  introduced  into  the 
human  body.     (See  page  263.) 

The  bacteria  of  food  poisoning  are  usually  associated  wdth 
putrefactive  organisms  which  are  present  almost  everywhere; 
but  the  substances  produced  by  the  specific  bacteria  are  not 


374  THE   HEALTH    OFFICER 

usually  unpleasant  to  the  senses,  and  they  may  be  present  in 
dangerous  amounts  while  the  food  is  apparently  fresh  and  in 
good  condition.  Most  foods  of  animal  origin  are  likely  to  be- 
come infected  or  to  undergo  natural  decomposition  much  more 
readily  than  those  of  vegetable  origin.  The  following  is  a  list 
of  the  ordinar}-  classes  of  foods  arranged  in  the  order  of  their 
liability  to  become  infected  or  decomposed: 

1.  Milk. 

2.  Crustaceans  (lobsters,  crabs,  etc.). 

3.  Shell-tish  (ovsters,  clams,  etc.). 

4.  Fish. 

5.  Meat. 

6.  Fruit. 

7.  Vegetables. 

8.  Cereals. 

Investigation  of  Food  Poisoning. — Since  food  poisoning  often 
has  the  nature  of  an  infectious  disease,  the  investigation  of  cases 
is  a  duty  of  a  department  of  health.  It  may  be  suspected  when 
its  symptoms  suddenh'  occur  in  a  group  of  persons  who  have 
used  a  particular  article  of  food  or  have  eaten  together.  The 
sanitary  code  of  Xew  York  State  requires  that  the  existence  of 
a  group  of  cases  shall  be  reported  to  the  health  officer  and  also 
to  the  state  commissioner  of  health  (Chapter  2,  Regulation  41). 
When  cases  are  reported,  the  procedures  that  a  health  officer  is 
to  take  are  as  follows: 

1.  Search  for  a  common  article  of  food  that  has  been  used  by 
all  the  affected  persons. 

2.  Obtain  a  sample  of  the  food,  place  it  on  ice,  and  send  it  to 
a  laboratory  for  a  bacteriologic  examination  and  a  determination 
of  the  type  of  its  organism,  if  any  be  present. 

3.  Search  for  the  primary  source  of  the  infection,  which  will 
probably  be  either  a  human  carrier,  or  an  unclean  shop  or  store, 
or  ice-box,  or  the  carcass  of  a  diseased  animal. 

4.  Take  the  necessary  steps  for  the  control  of  the  carrier, 
or  the  disinfection  of  the  infected  places,  or  the  destruction  of 
the  diseased  meat. 

Sausage  Poisoning. — A  special  form  of  food  poisoning  is  that 
known  as  botulismus,  or  sausage  poisoning.  It  is  caused  by 
the  Bacillus  botulismus.  The  bacilli  do  not  grow  in  the  living 
body,  but  grow  readily  upon  many  kinds  of  foods,  especially 
the  ground  meat  of  which  sausage  is  made,  for  the  grinding  will 
distribute  the  bacilli  from  a  small  focus  through  the  whole  mass. 
The  bacteria  produce  a  toxin  which  is  extremely  poisonous  when 
it  is  taken  into  the  stomach,  but  it  is  destroyed  by  the  heat  of 
cooking.     The  sources  of  the  bacilli  are  unclean  and  infected 


FOOD    SANITATION  375 

shops  and  utensils.  The  disease  may  be  prevented  by  cleanli- 
ness in  food  handling  and  by  thoroughly  cooking  the  food.  While 
it  is  a  rare  disease,  the  possibility  of  its  occurrence  is  an  argu- 
ment for  the  sanitary  control  of  places  for  the  sale  of  foods. 

Preserving  Agents. — The  decomposition  of  food  may  be 
prevented  to  a  great  extent  by  the  use  of  chemical  preservatives. 
These  substances  are  antiseptic,  and  often  have  a  poisonous 
action  upon  the  human  body.  Their  use  constitutes  a  form  of 
adulteration  which  is  forbidden  by  the  Federal  Pure  Food  and 
Drugs  Act  (page  372). 

The  feeding  of  civihzed  people  could  not  be  done  according 
to  modern  standards  unless  large  amounts  of  perishable  food 
which  are  produced  in  seasons  and  places  of  plenty  are  pre- 
served and  transported  for  use  in  seasons  and  places  of  scarcity. 
The  efficient  methods  of  preserving  food  in  a  wholesome  state 
are:  1,  drying;  2,  canning;  3,  salting;  4,  pickHng;  5,  smoking,  and 
6,  cold  storage. 

The  wholesomeness  of  preserved  foods  depends  principally 
upon  four  factors,  as  follows: 

1.  Their  conditions  when  they  are  preserved. 

2.  The  cleanliness  and  care  with  which  they  were  handled 
during  their  preparation. 

3.  The  method  of  their  storage. 

4.  The  period  of  time  during  which  they  are  kept. 

The  processes  of  preservation  may  conceal  the  true  nature 
of  foods  to  a  great  extent,  and  give  many  opportunities  for 
fraud.  There  is  a  great  temptation  to  preserve  food  of  an 
inferior  quality  and  that  which  is  about  to  spoil,  and  to  keep  the 
preserved  products  for  long  periods  of  time  until  a  profitable 
sale  can  be  made.  But  if  the  preserving  is  done  honestly,  the 
products  will  be  as  wholesome  as  the  fresh  foods. 

Cold  Storage. — The  process  by  which  foods  are  preserved  in 
their  most  natural  condition  is  that  of  cold  storage.  The  busi- 
ness is  highly  specialized,  and  each  section  of  a  warehouse  is 
fitted  for  a  single  class  of  food.  The  temperatures  vary  from  a 
few  degrees  above  freezing,  for  fruit  and  eggs,  to  10°  F.  or  lower 
for  meat  and  fish.  The  periods  of  time  during  which  foods  will 
keep  fresh  and  wholesome  are  known  with  considerable  accuracy. 
Some  kinds  of  bacteria  and  molds  will  grow  at  temperatures 
below  freezing,  and  some  evaporation  of  water  continually  goes 
on.  A  year  is  about  the  limit  of  time  during  which  the  freshness 
and  wholesomeness  of  cold  storage  food  can  be  guaranteed. 

When  foods  that  have  been  properly  preserved  in  cold  stor- 
age are  removed  for  sale,  they  are  in  the  same  state  that  they 
were  when  they  were  put  in  storage.     Food  about  to  decom- 


376  THE   HEALTH    OFFICER 

pose  wall  quickly  decay  after  it  it  removed  from  the  warehouse, 
and  food  that  is  infected  will  remain  infected.  But  food  which 
is  fresh  and  of  good  quality  when  it  is  put  in  cold  storage  will 
remain  fresh  and  wholesome  while  it  is  in  storage,  and  will  keep 
fresh  for  a  reasonable  length  of  time  after  it  is  removed.  The 
people  of  cities  could  not  be  fed  without  cold  storage. 

Canned  goods  are  usually  sold  in  tin  containers.  A  can  is 
sealed  while  hot,  and  on  cooling  a  \-acuum  is  formed  and  the  ends 
of  the  can  are  forced  inward  by  the  pressure  of  the  air.  When 
fermentation  or  decomposition  occurs,  gas  forms  and  relieves 
the  vacuum  or  makes  pressure  within  the  can.  The  test  for 
the  freshness  of  foods  in  sealed  tins  is  the  degree  of  vacuum  or 
pressure  within  the  cans.  An  inspector  divides  abnormal  cans 
into  four  classes:  1,  swellers;  2,  springers;  3,  flippers;  and  4, 
leakers. 

An  inspector  will  first  notice  the  ends  of  a  can.  If  they  are 
convex,  gas  is  present  under  pressure,  and  the  can  is  a  sweller 
and  is  to  be  condemned. 

The  inspector  will  press  upon  the  end  of  a  can.  If  the 
opposite  end  bulges  out  with  a  snap,  the  can  is  a  springer  and 
its  contents  have  undergone  some  degree  of  fermentation  or 
decomposition. 

The  inspector  will  strike  the  end  of  a  can  flat  upon  a  table. 
If  there  is  a  small  amount  of  gas  in  the  can,  the  blow  will  cause 
the  bottom  of  the  can  to  bulge  out  and  remain  convex.  If  the 
convex  end  is  pressed,  it  will  spring  back  with  a  snap.  A  can 
that  reacts  to  this  test  is  a  flipper  and  its  contents  are  in  the  be- 
ginning stage  of  fermentation,  although  they  may  not  neces- 
sarily be  harmful  to  health. 

A  can  that  is  evidently  leaking  is  always  to  be  condemned. 

A  health  oflicer  or  housewife  can  readily  apply  these  tests  in 
detecting  canned  foods  which  are  presumably  unfit  for  food. 

Disease  Germs  in  Food. — Foods  may  transmit  diseases  to 
man  by  means  of  disease  germs  which  either  were  in  an  animal 
before  its  slaughter  or  were  introduced  into  the  food. 

Most  diseases  of  lower  animals  do  not  afi"ect  man,  but  a  few 
may  be  transmitted  to  human  beings,  among  them  being  an- 
thrax, glanders,  vaccinia,  rabies,  tetanus,  foot-and-mouth  dis- 
ease, trichinosis,  tapeworm,  and  tuberculosis.  Paratyphoid  fever 
in  cattle  is  of  importance  because  of  its  relation  to  food  poison- 
ing. The  principal  animal  diseases  which  have  a  relation  to 
human  food  are  trichinosis  (page  311),  tapeworm  (page  309), 
and  tuberculosis. 

Tuberculosis  is  common  among  cattle  and  pigs.  It  may  be 
detected  by  an  inspection  of  the  carcass  and  internal  organs  of 


FOOD   SANITATION  377 

the  slaughtered  animals.  The  signs  of  the  disease  arc  enlarged 
lymph-glands,  tubercles,  and  abscesses.  The  enlarged  glands 
are  usually  seen  in  the  neck  and  around  the  lungs  and  the  in- 
testine. Tubercles  are  white  bodies  like  pin-heads  scattered 
through  the  affected  tissues,  especially  of  the  lungs.  Abscesses 
are  the  result  of  a  breaking  down  of  the  glands  and  tubercles. 

Meat  Inspection. — The  inspection  of  meat  at  slaughter  houses 
by  trained  inspectors  is  a  necessary  measure  for  the  protection  of 
public  health.  The  departments  of  health  of  the  larger  cities 
require  that  animals  to  be  used  as  food  shall  be  slaugntered  at 
licensed  slaughter  houses  in  the  presence  of  trained  inspectors, 
but  in  rural  districts  animals  intended  for  local  consumption  are 
often  slaughtered  without  an  inspection  of  the  meat  or  of  the 
houses. 

An  inspection  is  made  of  the  living  animals  and  also  of  their 
carcasses  and  internal  organs.  Living  animals  are  condemned 
when  they  are  evidently  diseased  or  show  signs  of  sickness. 
When  a  slaughtered  animal  shows  signs  of  disease,  its  body  and 
internal  organs  are  laid  aside  and  examined  in  detail  later.  If 
the  disease  is  localized,  the  affected  parts  are  removed,  and  the 
remainder  of  the  carcass  is  usually  allowed  to  be  sold.  There 
seems  to  be  no  sanitary  reason  for  condemning  any  healthy 
edible  part  of  an  animal,  since  a  thorough  cooking  will  prevent 
the  transmission  of  disease  by  the  meat. 

Food  Infection. — The  infection  of  foods  with  the  bacteria  of 
human  diseases  is  of  special  importance  when  the  foods  are  to 
be  eaten  raw.  There  are  three  principal  sources  of  infection: 
1,  sewage;  2,  contaminated  water;  and  3,  human  carriers.  The 
foods  which  are  most  likely  to  become  infected  are  shell-fish  and 
green  vegetables. 

Oyster  Infection. — The  most  prolific  oyster  and  clam  grounds 
are  located  in  shallow  bays  and  estuaries  where  the  water  is 
likely  to  receive  sewage  from  houses  and  villages.  These  waters 
nearly  always  contain  colon  bacilli  which  are  derived  from  the 
banks  of  rivers  and  creeks  which  flow  into  them.  Oysters  feed 
by  extracting  bacteria  and  other  microscopic  plants  from  the 
water  which  passes  over  their  gills.  The  kinds  of  bacteria  that 
are  in  the  water  will  usually  be  found  in  the  Hquor  which  sur- 
rounds an  oyster  in  the  shell.  Colon  bacilH  are  nearly  always 
found  in  this  Hquor,  and  the  presence  of  a  few  is  not  considered 
to  be  abnormal  or  to  indicate  contamination. 

A  few  outbreaks  of  typhoid  fever  have  been  caused  by  eating 
raw  oysters  and  other  shell-fish  taken  near  the  mouths  of  sewers 
or  in  water  that  is  heavily  contaminated  wfth  sewage.  The 
likelihood  of  the  infection  of  oysters  with  typhoid  bacilli  is  in 


378  THE  HEALTH   OFFICER 

direct  proportion  to  the  contamination  of  the  water  with  colon 
bacilli.  The  principal  cause  of  the  infection  with  typhoid  ba- 
cilli has  been  the  practice  of  placing  oysters  in  the  mouths  of 
fresh-water  creeks  which  often  contain  sewage.  This  was  done 
in  order  to  make  them  appear  plump  because  of  the  entrance  of 
fresh  water  into  the  salt  llesh  of  the  oyster  by  the  process  of 
osmosis;  but  the  practice  is  no  longer  legal,  for  the  plumping 
simply  dilates  the  flesh  with  water,  and  it  may  produce  con- 
tamination of  the  oyster. 

While  the  temperature  of  the  water  is  below  40°  F.,  oysters 
keep  their  shells  closed  and  remain  in  a  state  of  hibernation. 
During  this  period  they  soon  digest  the  bacteria  that  lie  within 
their  shells,  and  remain  sterile  until  the  temperature  of  the  water 
rises  above  40°  F.  Since  oysters  are  usually  on  the  market 
during  the  cold  months  only,  their  hibernation  is  a  great  protec- 
tion against  infection. 

The  sanitary  standard  of  oysters  is  based  on  the  presence  of 
colon  bacilli  in  various  amounts  of  their  liquor.  Five  oysters 
are  chosen  from  a  lot,  and  three  cultures  are  made  from  each. 
One  c.c.  of  the  liquor  is  taken  for  the  first  culture,  to  c.c.  for  the 
second,  and  too  c.c.  for  the  third.  If  colon  bacilli  are  found 
in  the  too  c.c.  sample,  the  score  of  the  oyster  is  100.  If  they 
are  found  in  the  tV  c.c.  and  not  in  the  to^o  c.c,  the  score  is  10; 
and  if  in  the  1  c.c.  only,  the  score  is  1.  Allowance  is  made  for 
the  chance  that  colon  bacilli  might  be  found  in  a  tfo  c.c.  sample 
when  there  are  only  one  or  two  present  in  each  cubic  centimeter 
of  the  liquor.  A  maximum  total  score  of  50  is  allowed  for  the 
five  oysters.  This  practically  means  that  oysters  are  consid- 
ered wholesome  when  colon  bacilli  are  found  in  each  tV  c.c.  of 
their  liquor  if  they  are  not  found  frequently  in  tfo  c.c.  samples. 

Cooking  is  an  efficient  preventive  of  infection  from  eating 
contaminated  oysters. 

Vegetables  which  are  eaten  raw  may  become  infected  with 
typhoid  bacilli  when  they  are  fertilized  with  sewage  or  human 
excretions,  or  are  washed  in  contaminated  water,  or  handled  by 
a  carrier. 

Infection  from  Food  Handling.— Persons  who  are  afiflicted 
with  communicable  diseases,  or  are  carriers  of  disease  germs, 
may  introduce  disease  germs  into  foods  which  they  handle. 
Foods  may  be  divided  into  three  classes  according  to  their  like- 
lihood to  transmit  infection  from  those  who  handle  them  to  those 
who  eat  them: 

1.  Foods  which  are  to  be  cooked  before  they  are  eaten  are 
not  likely  to  transmit  infection. 

2.  Foods  which  are  to  be  eaten  raw  are  possible  sources  of 


FOOD   SANITATION 


379 


infection,  but  are  not  likely  to  be  dangerous  provided  they  are 
properly  cleansed. 

3.  Foods  in  kitchens  and  those  which  are  ready  to  be  served 
at  table  are  likely  to  transmit  infection  from  infected  cooks, 
waiters,  and  clerks.  Soups,  meat  broths,  stews,  and  boiled 
potatoes  are  similar  to  the  culture-media  used  in  laboratories, 
and  when  they  are  infected,  bacteria  of  disease  may  grow  in 
them  readily.  Lunch  counters,  restaurants,  delicatessen  stores, 
and  other  places  in  which  food  is  sold  ready  to  be  eaten  spread 
diseases  far  more  readily  than  butcher  shops,  groceries,  and 
similar  food  stores  in  which  most  of  the  foods  sold  are  cooked 
or  cleansed  before  they  are  eaten. 


^"^^Z. 


■■imii^ 


^-"■^  M,^  ^'^ 


Fig.  36. — The  back  door  of  a  restaurant  that  needs  a  visit  from  the  health  ofEcer. 

The  principal  diseases  which  are  transmitted  by  means  of 
foods  are  those  of  the  intestine,  especially  typhoid  fever.  Cooks 
have  been  known  who  have  been  spreaders  of  typhoid  fever  for 
years,  and  have  produced  cases  in  nearly  every  place  in  which 
they  work.  These  carriers  may  be  detected  by  modern  methods 
of  laboratory  examinations  of  their  excretions. 

Diseases  of  the  throat  and  respiratory  organs  may  also  be 
transmitted  by  means  of  foods  which  are  handled  by  infected 
persons  or  carriers.  The  best  known  examples  of  diseases  which 
are  food-borne  are  septic  sore  throat,  diphtheria,  and  scarlet 


380  THE   HEALTH    OFFICER 

fever  by  means  of  milk;  but  any  other  cooked  food  may  also 
transmit  the  diseases. 

Prevention. — The  prevention  of  food  infection  and  of  food- 
borne  diseases  consists  in: 

1.  The  education  of  the  public. 

2.  The  inspection  of  places  in  which  food  is  prepared  and 
sold. 

Public  education  regarding  food-borne  diseases  may  be  con- 
ducted along  two  general  lines: 

1.  Instruction  regarding  the  preparation  of  foods  so  as  to 
destroy  whatever  infection  that  may  be  in  them. 

2.  Arousing  the  public  to  demand  cleanliness  and  sanitary 
methods  of  handling  foods  in  places  in  which  foods  are  sold. 
Financial  loss  from  lack  of  trade  is  an  effective  means  of  influenc- 
ing food  dealers  to  adopt  sanitary  methods  of  food  handling. 

Food  Inspection. — An  ideal  system  of  food  inspection  will 
embrace  every  stage  of  the  production  of  a  food  from  the  crude 
article  to  its  delivery  to  the  consumer.  The  most  practical 
system  for  an  ordinary  board  of  health  to  adopt  is  that  of  in- 
specting foods  when  they  are  ready  for  delivery  to  the  custom- 
ers. The  inspections  will  include  restaurants,  lunch  counters, 
ice-cream  parlors,  soda-water  fountains,  oyster  houses,  candy 
shops,  delicatessen  stores,  and  other  places  in  which  foods, 
drinks,  or  confectionery  are  sold. 

Inspector's  Score  Card. — ^An  outline  of  the  items  to  be  no- 
ticed during  an  inspection  is  contained  in  a  score  card,  called 
the  United  States  Standard  Score  Card,  a  copy  of  which  is  found 
on  page  381.  The  card  was  designed  for  the  use  of  the  officers 
of  the  United  States  Public  Health  Service,  and  is  similar  to 
that  used  in  inspecting  dairies.  The  figures  on  the  score  card 
may  be  criticized  on  the  ground  of  the  impossibility  of  assigning 
fixed  values  to  conditions  which  are  variable;  but  the  items 
constitute  a  standard  guide  for  the  inspection  of  any  place  in 
which  foods,  drinks,  or  confectionery  are  sold.  An  inspector 
is  also  to  note  the  surroundings  of  an  eating  or  drinking  estab- 
lishment, and  to  condemn  those  which  are  located  near  a  stable 
or  open  cesspool,  or  privy,  or  other  gross  source  of  infection. 

Examination  of  Food  Handlers. — It  is  important  that  no 
person  who  is  affiicted  with  a  communicable  disease,  or  is  a 
carrier,  be  allowed  to  work  as  a  cook  or  kitchen  helper,  or  waiter, 
or  to  serve  foods,  drinks,  or  confectionery.  While  carriers  are 
few  in  number,  yet  the  danger  from  them  is  so  great  that  exten- 
sive investigations  for  their  detection  and  exclusion  from  eating 
houses  are  justifiable.  Those  who  are  grossly  affected,  or  have 
open  lesions,  may  be  discovered  by  a  physical  examination;  and 


FOOD   SANITATION 


381 


Sanitary  Inspection  of  Places  Where  PocrIs  are  Prepared  lor  Sale  or  Sold 

Owner  or  Managrer 

Trade  Name......^ • • 

Street  and  No ." *. • /  —  ...,..••. 

Resiatralion  No .Date  of  Inspeirtlon 


Score  for  equipment ;      multiplied  by  1 

Score  for  metbods multiplied  by  2 

Total  to  b$  divided  by  3 

Pinal  Score 


Score 

Iletbods 

Score 

Equipment 

Perfect 

Allowed 

Perfect 

Allowed 

Plant 

7 
2 

J 

4 

3 
6 
5 
6 
3 

10 
10 

15 
5 
5 

15 
5 

Plant 

5 
3 

1 

1 

1 

I 

2 
6 

10 
5 
5 

10 

5 

10 
JO 
5 
5 

6 
6 
5 

Floors  and  Drainage. . 

Arrangement.' 7 

Free  from  Odor 

Freedom  from  Files. . . 

Equipment  (CleanlinesB).. 

30 

VeDtilatioD 

Cellar. 

Plumbing 20 

(Kind.qusiity,  location 

and  condition)  .  < 

Water  Closets  .  ....... 

SinkB 

Utensils 

Employees'  Cleanliness . 

Equipment .-•es 

(Klnd.quBlity.arrange- 
ment) 

Tables. 

- 

Utensils ,... 

Garbage  Receptacles.. 15 
Adequate 

^ater  lor  Cleaning 20 

Hot 

Cold 

Condition 

100 

Additional  Deductions 
'for  Exceptionally  Bad 
Conditions. 

100 

Additional  Deduc  ti  on  s 
for  Exceptionally  Bad 
Conditions. 

Total  Deductions 

Total  Deductions 
Net  Total 

Net  Tgtal 

REMARKS.    (To  cover  such  dnusual  conditions  as  sleeping  accommodations,  or  the  presence 
nf  domestic  animals  in  or  about  work  room,  etc.) , 


inspector 

Fig.  37.— The  United  States  Standard  Score  Card. 


those  ^yho  are  carriers  may  be  detected  by  a  bacteiiologic  ex- 
amination of  their  excretions.  Boards  of  health  are  beginning 
to  require  a  medical  examination  and  certificate  of  freedom  from 


382 


THE   HEALTH   OFFICER 


communicable  diseases  from  workers  in  restaurants;  and  boards 
in  the  larger  cities  are  requiring  a  bacteriologic  examination  of 
their  excretions. 

Sterilizing  Dishes. — Dishes  in  which  foods  are  served  to 
patrons  and  the  utensils  with  which  they  are  eaten  are  con- 
taminated with  the  excretions  from  the  hands,  mouths,  and  noses 
of  the  customers.  The  only  practical  method  of  sterilizing  them 
is  by  the  use  of  boiling  water.  A  simple  method  of  sterilizing 
them  is  to  wash  them  in  the  ordinary  way  in  soap  and  hot  water, 
and  then  place  them  in  a  wire  basket  and  dip  them  into  a  large 
kettle  of  boiling  water  w^hich  is  kept  on  a  stove  for  that  special 
purpose.     Dishes  which  are  dipped  in  boiling  water  require  no 


4 


Fig.  38. — Dish-washing — a  simple,  efficient  method  of  sterilizing  the  dishes. 


wiping,  and  thus  they  escape  contamination  from  extra  hand- 
ling and  from  soiled  towels  which  are  often  used  in  dr}4ng  them. 
The  economy  of  help  required  more  than  compensates  for  the 
expense  of  the  fire. 

The  glasses  and  dishes  at  soda-water  fountains  and  ice-cream 
parlors  are  often  cleansed  by  placing  them  over  upright  brushes 
through  which  cold  water  flows.  These  brushes  cannot  be  kept 
sterilized,  or  even  clean,  and  are  often  sources  of  gross  cqntamina- 
tion  unless  the  utensils  are  afterward  dipped  in  boiling  wa.ter. 
The  use  of  paper  containers  is  an  economic  sanitary  method  of 
ser\-ing  cold  drinks  and  ice-cream. 

Food  Regulations. — The  presence  of  large  camps  of  laborers 


FOOD    SANITATION  383 

engaged  in  building  army  cantonments  has  aroused  the  civil 
population  to  the  necessity  of  food  regulations  similar  to  those 
which  are  adopted  in  armies.     A  simple  code  is  as  follows: 

No  food  or  drink,  or  material  for  making  food  or  drink,  shall 
be  sold  unless  it  is  kept  and  dispensed  in  clean,  closed,  sanitary 
containers,  and  is  handled  in  a  clean  and  sanitary  manner. 

No  food  or  drink  shall  be  sold  or  exposed  for  sale  unless  it  is 
kept  covered  in  such  a  manner  that  it  is  protected  against  flies 
and  dust. 

No  person  whose  hands  or  clothes  are  in  an  unclean  condi- 
tion shall  handle  or  dispense  food  or  drink  that  is  exposed  for 
sale. 

No  food  or  drink  shall  be  sold  or  exposed  for  sale  in  stores, 
stalls,  or  wagons  which  are  in  an  unclean  or  unsanitary  condition.' 

No  food  or  drink  shall  be  sold,  or  offered  for  sale,  or  dispensed 
in  dishes  which  have  been  previously  used,  unless  the  said  dishes 
shall  have  been  adequately  cleansed  with  boiling  water. 


CHAPTER  XXXIV 

FOOD  VALUES 

The  scientific  principles  of  feeding  have  long  been  applied  to 
domestic  animals.  Agricultural  papers  discuss  the  diets  of  cat- 
tle, and  tell  what  foods  and  how  much  are  required  to  produce 
a  150-pound  calf  or  to  support  a  working  horse.  The  same 
principles  may  be  applied  to  produce  a  150-pound  boy  who  has 
the  natural  vigor  and  grace  of  a  healthy  calf,  or  to  maintain  a 
workingman  with  the  strength  and  activity  of  a  sleek  working 
horse.  Feeding  human  beings  is  becoming  an  exact  science, 
whose  elementary  principles  are  few  and  may  be  readily  under- 
stood. Writings  on  human  diets  are  often  bare  statements  of 
advice  like  dogmatic  rules  in  arithmetic  without  explanations  of 
the  reasoning  on  which  the  rules  are  founded.  When  the  founda- 
tion principles  of  dieting  are  understood,  an  intelligent  person 
can  apply  them  in  the  choice  of  food  and  the  manner  of  feeding. 
It  is  necessary  that  a  health  officer  should  know  and  understand 
the  scientific  basis  of  food  values,  for  nutrition  has  a  direct 
bearing  on  physical  and  mental  vigor,  and  on  immunity  to 
diseases. 

Food  substances  are  divided  into  three  classes: 

1.  Building  foods. 

2.  Fuel  foods. 

3.  RegulatiN^e  foods,  or  those  which  have  a  direct  influence 
on  the  process  of  tissue  building  and  the  utilization  of  fuel  foods. 

Building  Foods. — Every  kind  of  living  matter  consists  of  a 
mixture  of  protein,  water,  and  minerals.  These  three  substances 
compose  the  flesh,  blood,  and  bone  of  the  human  body.  Build- 
ing foods  are  required  for  two  purposes:  1,  for  growth,  and  2, 
for  the  repair  of  worn-out  parts. 

Protein  consists  of  carbon,  hydrogen,  and  oxygen,  together 
with  nitrogen  and  sulphur.  It  is  a  complex  substance,  and 
exists  in  various  forms  in  the  human  body.  Examples  of  pro- 
tein are  lean  meat  and  the  white  of  an  egg.  The  body  needs 
about  3  ounces  of  protein  daily. 

Minerals  are  the  ashes  that  are  left  after  a  substance  is 

burned.     They  consist  of  such  material  as  lime,  soda,  potash, 

and  iron.     They  are  found  in  nearly  all  kinds  of  foods,  and  are 

intimately    joined    to    the    proteins    in    organic    combinations. 

384 


FOOD    VALUES  385 

Minerals  added  to  food  cannot  take  the  place  of  those  which 
are  naturally  there.  We  usually  get  sufficient  mineraJ-building 
material  when  we  eat  the  proper  amount  of  other  substances. 
They  also  have  important  uses  as  regulative  foods  (page  394). 

Water  enters  and  leaves  the  body  unchanged  in  its  form  or 
composition.  Its  quantity  in  the  flesh  or  blood  may  vary  con- 
siderably from  time  to  time.  It  is  a  vehicle  in  which  all  other 
body  substances  are  dissolved.  There  is  only  one  kind  of  water, 
and  httle  need  be  said  about  it  in  a  discussion  of  food  values. 

Fat  is  also  found  in  the  body,  but  little  or  none  of  it  con- 
sists of  fat  that  is  eaten.  It  is  manufactured  principally  from 
protein  which  the  body  does  not  need  for  other  purposes. 

Fuel  Foods. — The  food  which  a  grown  person  takes  into  his 
blood  in  a  day  would  weigh  about  1  pound  if  it  were  dried,  and 
yet  it  disappears  and  the  body  does  not  gain  in  weight.  The 
explanation  is  that  it  is  burned,  or  oxidized,  in  the  body.  The 
second  great  class  of  foods  consist  of  those  which  the  body  uses 
as  fuel.  The  oxygen  which  the  body  uses  in  oxidizing  its  fuel 
food  weighs  about  ^  pound  more  than  the  food,  excepting  water. 

The  process  of  oxidation  in  the  body  has  two  uses:  1,  to  pro- 
duce heat  for  warming  the  body,  and  2,  to  produce  power  for 
doing  muscular  work.  A  person  doing  muscular  work  burns 
food  rapidly,  and  becomes  warm.  The  body  is  a  heat  engine, 
and  is  run  by  means  of  the  heat  of  its  burning  food.  Only  one- 
quarter  of  the  total  amount  of  the  heat  produced  by  the  food 
can  be  used  in  developing  power  in  the  body.  But  the  body 
engine  is  twice  as  efficient  as  the  best  steam  engine,  for  the 
steam  engine  can  turn  only  about  one-tenth  of  its  heat  into  power. 

The  fuel  foods  are  starches,  sugars,  and  fats.  They  are 
composed  of  carbon,  hydrogen,  and  oxygen,  with  no  nitrogen  or 
sulphur.  Starches  and  sugars  are  often  called  carbohydrates. 
Nearly  all  the  fuel  foods  are  oxidized  soon  after  they  enter  the 
body. 

The  worn-out  parts  of  the  body  consist  principally  of  protein 
which  has  been  oxidized.  A  grown  person  needs  protein  for 
the  purpose  of  replacing  that  part  of  his  living  flesh  which  has 
been  oxidized.  We  may,  therefore,  call  protein  a  fuel  food  as 
well  as  a  building  food. 

Composition  of  Foods. — Foods  may  be  divided  into  those 
derived  from  animals  and  those  derived  from  vegetables.  Ani- 
mal foods  are  rich  in  protein,  and  so  also  are  peas  and  beans. 
These  are  popularly  called  building  foods.  They  usually  con- 
tain considerable  amounts  of  fat,  and  are,  therefore,  fuel  foods 
also.  No  animal  food,  except  milk,  contains  carbohydrates  in 
important  quantities.     Cereals,  potatoes,  and  some  fruits  have 

25 


386  THE    HEALTH    OFFICER 

a  large  proportion  of  sugar  or  starch  and  are,  therefore,  called 
fuel  foods.  But  nearly  all  contain  some  protein,  and  are,  there- 
fore, to  be  classified  as  building  foods  also.  Garden  vegetables 
and  the  juicy  fruits  contain  little  protein  or  carbohydrates,  and 
their  value  for  building  or  fuel  is  small.  Their  principal  value 
is  that  they  contain  regulative  substances  which  are  essential  to 
health  and  growth. 

The  value  of  foods  for  building  or  fuel  may  be  estimated  from 
tables  of  their  chemical  composition.  The  tables  usually  give 
the  proportion  of  protein,  carbohydrate,  fat,  and  mineral  matter 
in  the  various  foods,  but  they  afford  little  basis  for  estimating 
their  content  of  regulative  foods.  The  following  table  is  a 
general  summary  of  the  composition  of  the  various  classes  of 

foods : 

Animal  Food. 

Per  cent. 

Protein 10  to  30 

Fat 10  to  75 

Sugar  or  starch Practically  none. 

Cereals,  Potatoes,  Beans,  Etc. 

Per  cent. 

Sugar  or  starch 5  to  50 

Protein 2  to  20 

Fat 0  to  10 

Fruit  and  Garden  Vegetables 

Per  cent. 

Sugar  or  starch 1  to  10 

Protein 1  to    5 

Fat Practically  none. 

Oxidation  of  Food. — The  oxidation  of  food  in  the  body  is 
similar  to  the  oxidation  of  wood  in  a  stove.  Food  unites  with 
oxygen  in  the  body,  and  becomes  smoke  and  ashes  and  produces 
heat.  The  oxidation  of  the  carbon  of  either  protein,  carbohy- 
drates, or  fats  produces  carbon  dioxid,  and  the  oxidation  of 
hydrogen  produces  water.  These  are  the  principal  substances 
in  the  smoke  of  a  burning  fire.  Neither  of  them  is  harmful  to 
the  body  unless  it  is  present  in  excessive  quantity.  Each  is 
excreted  from  the  body  by  an  easy  and  simple  process. 

The  oxidation  of  the  nitrogen  and  sulphur  of  protein  pro- 
duces an  ash  which  has  an  acid  reaction.  A  certain  degree  of 
alkalinity  of  the  blood  and  tissues  is  necessary  for  health,  and 
when  it  is  reduced,  the  body  suffers  in  health  and  vigor.  A  diet 
containing  a  large  proportion  of  meat,  or  eggs,  or  other  animal 
food  is  harmful  on  account  of  the  acid  ash  left  after  the  oxida- 
tion of  its  protein.  The  excretion  of  the  acids  overtaxes  the 
liver  and  produces  what  the  older  physicians  called  biliousness; 


FOOD    VALUES  387 

and  the  acids  circulating  in  the  blood  produce  gout,  rheumatism, 
and  pains  in  the  joints  and  muscles.  The  more  remote  effects 
of  an  excessive  protein  diet  are  kidney  troubles,  hard  arteries, 
and  premature  old  age. 

The  ash  left  by  cereals  and  most  other  vegetable  foods  is 
strongly  alkaline,  and  is  beneficial  to  the  body.  Its  alkalinity 
is  due  to  the  small  proportion  of  protein  in  the  foods,  and  also 
to  the  large  proportion  of  alkaline  minerals  in  them.  One  of 
the  fundamental  principles  of  dieting  is  to  eat  no  more  protein 
than  is  needed  to  replace  the  worn-out  protein  of  the  living  flesh. 
This  may  usually  be  accomplished  by  eating  sparingly  of  meat 
and  other  animal  foods,  and  using  cereals  and  vegetables  in  their 
place.  Milk  and  milk  products  are  exceptions  to  this  rule,  for 
they  contain  protein  and  alkaline  minerals  in  a  proper  combina- 
tion for  health. 

We  recognize  two  types  of  men  in  the  relation  of  their  food 
to  oxidation.  A  stout  man  has  a  large  stomach  and  fuel  capac- 
ity, and  small  lungs  and  oxidizing  ability.  His  stomach  can 
supply  fuel  faster  than  his  lungs  can  furnish  oxygen  to  oxidize 
it.  He  will  be  likely  to  be  short  of  breath  and  asthmatic,  and 
to  have  trouble  with  his  liver,  kidneys,  and  arteries.  He  will 
probably  be  benefited  by  living  on  coarse,  unnutritious  food. 
His  stomach  can  usually  extract  sufficient  nutritive  matter  from 
coarse  foods,  such  as  spinach,  turnips,  and  cabbage.  If  he  lives 
on  such  foods  as  these,  he  may  safely  satisfy  his  hunger  and 
appetite  without  exceeding  his  oxidizing  capacity. 

A  lean  athlete  has  large  lungs  and  a  small  stomach.  His 
digestive  power  is  small  and  is  constantly  overtaxed  in  supply- 
ing sufficient  food  to  replace  that  which  is  oxidized  by  the  large 
lungs.  This  man  will  thrive  on  a  concentrated  diet.  He  can 
take  an  excess  of  protein  with  little  harm,  for  he  can  oxidize 
it  well.  His  worst  troubles  are  likely  to  be  indigestion  and 
dyspepsia. 

The  relation  of  the  stomach  to  the  lungs  will  explain  many 
of  the  contradictory  observations  about  dieting.  The  lungs  and 
the  oxidizing  capacity  of  the  body  must  always  be  considered  in 
discussing  a  person's  food. 

Caloric  Value. — One  standard  of  the  value  of  various  foods 
is  the  proportion  of  protein  in  them;  another  is  their  mineral 
composition;  and  another  is  their  content  of  regulative  sub- 
stances; but  the  standard  of  the  broadest  application  is  their 
fuel  value.  The  heating  capacity  of  foods  is  the  standard  of 
their  value  which  is  usually  given  in  tables  of  food  composition. 
About  nine-tenths  of  the  subject  of  dieting  concerns  the  fuel 
value  of  foods.     The  body  must  oxidize  a  certain  amount  of 


388 


THE   HEALTH    OFFICER 


fuel  food  in  order  to  do  a  given  amount  of  work.  These  quan- 
tities have  been  determined  by  obserN-ing  men  who  Hve  for  days 
in  a  closed  chamber  which  is  provided  with  means  for  analyzing 
the  air,  the  food,  and  the  excretions,  and  for  measuring  the 
quantity  of  heat  that  the  man  produces  and  the  amount  of 
physical  work  which  he  performs.  The  results  may  be  applied 
accurately  in  providing  food  for  armies,  exploring  expeditions, 
and  institutions.  They  also  give  accurate  results  in  feeding 
individuals. 

The  fuel  value  of  a  food  is  found  by  burning  a  weighed  quan- 
tity of  dried  food  in  a  piece  of  apparatus  called  a  calorimeter. 
The  case  containing  the  food  is  surrounded  by  water.     When 


Fig.  39. — A  simple  form  of  calorimeter:  a,  Inner  cell  in  which  food  is  burned; 
b,  cylinder  in  which  a  is  enclosed;  r,  water  container  in  which  a  and  b  are  immersed. 
The  number  of  calories  is  estimated  by  the  change  in  temperature  of  the  water. 


the  amount. of  food,  the  quantity  of  water,  and  the  increase  in 
the  temperature  of  the  water  are  known,  the  amount  of  heat 
produced  by  a  unit  of  weight  of  food  may  be  easily  calculated. 
Quantities  of  heat  are  measured  in  calories.  One  calorie  is 
the  amount  of  heat  that  will  raise  1  kilogram  of  water  1°  C. 
This  is  nearly  the  amount  that  will  raise  1  pint  of  water  1°  F.; 
100  calories  will  raise  a  quart  of  ice-cold  water  nearly  to  the 
boiling-point;  2500  calories  will  raise  75  quarts  of  water,  which 
is  nearly  the  volume  of  the  body,  from  a  freezing  temperature  to 
that  of  the  normal  body.  A  person  doing  light  work  needs  to 
produce  about  2500  calories  daily,  and  one  at  heavy  work,  3500 
or  4000  calories. 


FOOD    VALUES  389 

The  adult  human  body  produces  heat  at  about  the  same  rate 
as  two  burning  candles  of  tallow  or  paraffm.  An  ordinary 
candle  weighs  1  ounce,  will  burn  four  hours,  and  will  produce 
240  calories  of  heat.  Two  candles  burning  continuously  for 
twenty-four  hours  will,  therefore,  produce  2880  calories  of 
heat. 

Balanced  Diet. — The  body  is  designed  to  oxidize  food  ele- 
ments in  certain  proportions.  The  protein  which  it  is  designed 
to  oxidize  is  that  which  forms  a  part  of  the  living  flesh  of  the 
muscles.  Protein  is  a  poor  fuel  food,  and  is  oxidized  with  dif- 
ficulty. It  is  also  much  more  expensive  than  the  proper  fuel 
foods — starch,  sugar,  and  fat. 

Fat  enters  the  blood-stream  just  as  the  blood  is  approaching 
the  lungs.  Most  of  the  fat  is  probably  oxidized  in  the  lungs. 
Starch  and  sugar  enter  the  blood-stream  in  the  intestine,  and 
are  carried  to  the  Uver.  The  best  health  is  maintained  when 
oxidation  in  the  muscles,  the  lungs,  and  the  liver  is  maintained 
in  the  proper  balance.  A  diet  containing  protein,  fat,  and 
carbohydrate  in  the  proper  proportions  is  called  a  balanced  diet. 
A  standard  proportion  is  that  one-sixth  of  the  calories  shall 
come  from  protein,  two-sixths  from  fat,  and  three-sixths  from 
carbohydrate. 

The  effects  of  an  unbalanced  diet  may  be  illustrated  by  candy 
eating.  When  an  excess  of  sugar  is  eaten,  oxygen  will  combine 
with  it  more  readily  than  with  protein.  The  protein  will  then 
be  imperfectly  oxidized,  and  will  harm  the  body  in  the  same 
manner  that  an  excess  of  protein  in  the  diet  would.  The  rapid 
oxidation  of  alcohol  in  the  body,  and  its  effect  in  robbing  the 
protein  of  oxygen,  account  for  many  of  the  evil  effects  of  strong 
drink. 

The  subject  of  balanced  diet  is  also  concerned  with  the  regu- 
lative substances  that  are  found  in  foods  (page  394). 

The  body  has  an  immediate  and  frequent  need  for  fuel  food. 
It  can  go  only  a  few  hours  without  requiring  a  new  supply  of 
fuel;  but  it  can  go  a  few  days  without  sufficient  building  food; 
and  it  can  go  for  possibly  a  month  without  regulative  foods. 
Fuel  foods  are  used  up  rapidly  and  a  new  supply  is  normally 
required  three  times  a  day.  Protein  for  building  is  used  only 
one-sixth  as  rapidly  as  fuel  food;  and  regulative  foods  are  used 
still  more  slowly.  The  subject  of  the  caloric  value  of  foods  is 
fundamental,  and  must  receive  first  consideration  in  the  estima- 
tion of  the  value  of  every  diet.  A  dietitian  must  think  in  terms 
of  calories,  and  deal  with  figures  which  are  fairly  accurate  and 
uniform. 

Calories  in  Food. — One  ounce  of  protein,  or  starch,  or  sugar 


390 


THE    HEALTH    OFFICER 


will  produce  120  calories  of  heat;  and  1  ounce  of  fat  will  produce 
240  calories.  If  we  know  the  composition  of  a  food,  we  may 
easily  calculate  how  many  calories  it  will  produce.  For  example, 
how  many  calories  will  a  pound  loaf  of  bread  produce? 

The  composition  of  bread  is  approximately  50  per  cent, 
carbohydrate  and  10  per  cent,  protein. 

16  oz.  X  0.50  =  8  oz.  carbohydrate;  X  120  =  960  calories. 

16  oz.  X  0.10  =  1.6  oz.  protein;  X  120  =  192  calories. 

960+  192  =  1152  calories. 

The  100  Calory  Standard. — The  greater  part  of  the  study 
of  dieting  consists  in  becoming  familiar  with  the  number  of 


mff/^-iimi^-saisssa.^ . 


Fig.  40. — Number  of  calories  in  a  simple  breakfast. 


calories  that  are  produced  by  various  dishes  as  served  at  table. 
The  subject  is  much  simplified  by  the  possibility  of  adopting  a 
simple  rule  of  almost  universal  application.  This  rule  is  as  fol- 
lows: 

A  rather  small  portion  of  food  as  ordinarily  served  at  table 
will  contain  about  loo  calories. 

This  rule  is  broad  and  general,  but  is  a  standard  from  which 
to  begin  the  estimation  of  the  value  of  any  particular  food,  and 
the  results  of  its  application  are  found  to  be  fairly  accurate  in 
actual  practice.  The  following  amounts  of  various  foods  each 
contain  about  100  calories: 


FOOD    VALUES  391 

Bread — a  rather  thick  slice. 

A  biscuit  or  bun. 

Flour — a  heaping  tablespoonful. 

Four  Uneeda  Biscuits. 

Three  graham  crackers. 

A  shredded  wheat  biscuit. 

Two  or  three  pancakes. 

Two  lady  fingers. 

One  large  cooky. 

A  small  helping  of  layer  cake. 

One-sixth  or  one-twelfth  of  a  pie. 

A  potato  of  ordinary  size. 

A  small  sweet  potato. 

Beans,  boiled  or  baked,  one  or  two  tablespoonfuls. 

Oatmeal,  cornmeal,  hominy,  rice,  macaroni,  farina,  as  ordi- 
narily cooked,  three  or  four  tablespoonfuls. 

A  small  lamb  chop. 

A  small  helping  of  bacon,  beefsteak,  pork,  or  chicken. 

A  small  codfish  steak. 

An  ordinary  glass  of  milk. 

Cream,  3  tablespoonfuls. 

Butter,  an  ordinary  helping. 

Olive  oil,  one  tablespoonful. 

One  large  egg. 

Sugar,  2  or  3  heaping  teaspoonfuls,  or  4  cubes. 

Maple  syrup,  1  or  2  tablespoonfuls. 

One  large  apple. 

Apple  sauce,  2  tablespoonfuls. 

Six  cooked  prunes  with  their  juice. 

A  large  fig. 

Three  peaches. 

A  banana. 

A  small  bunch  of  grapes. 

Three  large  dates. 

An  ear  of  green  corn. 

Thick  vegetable  soup  (puree) — one  plateful. 

Ordinary  soups  and  broths — 2  or  3  quarts. 

The  garden  vegetables,  such  as  tomatoes,  string  beans,  tur- 
nips, cabbage,  and  carrots,  and  those  used  as  salads,  have  very 
little  value  as  fuel  or  as  building  foods.  They  will  be  discussed 
under  regulative  foods. 

Fat  has  twice  the  caloric  value  of  protein  or  carbohydrates. 
Anything  containing  a  large  proportion  of  fat  will,  therefore, 
produce  a  large  amount  of  heat.  What  are  popularly  called 
rich  foods  usually  contain  much  fat. 


392  THE   HEALTH    OFFICER 

The  caloric  value  of  a  food  will  depend  also  upon  the  con- 
centration of  the  oxidizable  elements.  ]\Iost  pies  and  cakes 
have  a  high  caloric  value  on  account  of  their  richness  in  fat  and 
sugar.  Desserts  are  usually  eaten  after  a  full  meal  of  other 
foods,  and  the  result  often  is  that  an  excessive  amount  of  fuel 
food  is  taken,  and  the  oxidizing  capacity  of  the  body  is  exceeded. 

Candy,  ice-cream,  soda  water,  and  the  more  solid  fruits  are 
foods.  They  are  often  eaten  between  meals  under  the  impres- 
sion that  they  have  no  effect  on  nutrition.  They  usually  have  a 
considerable  caloric  value,  and  when  they  are  eaten  between 
meals,  the  calories  which  they  produce  are  to  be  added  to  those  of 
the  regular  meals. 

Milk  is  also  to  be  considered  as  a  food  rather  than  a  drink. 
A  pint  will  produce  over  300  calories,  and  8  pints  or  4  quarts  a 
day  w'ill  supply  all  the  food  needed  by  a  person  doing  light  work. 
A  glass  or  two  of  milk  at  the  end  of  a  meal  or  between  meals 
supplies  a  considerable  amount  of  fuel  food  which  must  be 
oxidized. 

Tea,  coffee,  and  cocoa  in  themselves  have  little  or  no  food 
value,  but  when  the  drinks  are  prepared  with  milk  and  sugar, 
each  cupful  will  supply  about  100  calories. 

If  we  know  the  caloric  value  of  the  various  t}^ical  foods, 
we  can  readily  arrange  a  bill  of  fare  to  supply  the  required  num- 
ber of  calories.  Since  the  daily  requirement  for  a  person  at 
light  work  is  2400  calories,  each  meal  must  supply  about  800 
calories.  There  are  two  methods  of  ordering  a  meal  which  shall 
contain  the  required  number  of  calories.  The  first  is  to  look  over 
a  list  of  foods  and  their  calories,  and  choose  a  sufficient  amount 
to  produce  800  calories.  This  method  involves  a  considerable 
amount  of  skill  in  figuring  and  planning,  and  the  results  are  not 
satisfactory  unless  one  is  an  expert.  Eating  by  rule  is  usually 
irksome,  and  does  not  work  well  in  practice.  The  second  method 
is  to  choose  a  meal  according  to  our  desires,  just  as  folks  did 
before  calories  were  known.  We  can  then  reckon  the  number  of 
calories  in  a  meal  and  increase  or  diminish  the  quantity  of  cer- 
tain dishes  as  is  necessary. 

Utilization  of  Foods. — The  utilization  of  foods  which  are 
eaten  consists  of  two  processes:  1,  digestion,  or  the  preparation 
of  foods  for  their  entrance  into  the  blood-stream;  and  2,  assimila- 
tion, or  the  uses  to  which  they  are  put  by  the  living  tissues 
throughout  the  body. 

Human  foods  are  second-hand  materials  which  have  pre- 
viously formed  a  part  of  the  body  of  a  lower  animal  or  of  the 
substance  of  a  plant.  Proteins,  carbohydrates,  and  fats  are  com- 
plex substances,  and  are  composed  of  simpler  elements  which 


FOOD    VALUES  393 

may  be  compared  to  the  bricks  and  boards  of  which  a  house  is 
made.  Foods  as  eaten  are  in  the  condition  of  a  house  which  is 
to  be  torn  down  in  order  that  its  simple  materials  may  be  re- 
covered. The  object  of  digestion  is  to  tear  the  elements  apart 
and  reduce  them  to  a  condition  resembling  that  of  the  individual 
bricks  and  boards  of  a  wrecked  building.  Only  the  simple  ele- 
ments can  pass  through  the  lining  of  the  intestine  and  enter  the 
blood-stream. 

The  assimilation  of  food  after  it  has  entered  the  blood  con- 
sists either  in  the  oxidation  of  the  simple  food  elements  or  in 
rebuilding  the  protein  elements  into  new  combinations  in  the 
tissues  of  the  body. 

The  digestion  of  a  carbohydrate  consists  of  its  reduction  to 
a  simple  form  called  maltose.  Carbohydrates  are  divided  into 
three  groups  of  substances:  1,  the  celluloses;  2,  the  starches;  and 
3,  the  sugars.  Cellulose  is  the  fibrous  parts  of  a  plant,  such  as 
cotton  and  wood.  Man  cannot  digest  cellulose,  although  cattle 
may  do  so.  Man  digests  starch  imperfectly  when  it  is  raw,  but 
he  digests  it  readily  when  it  is  well  cooked  and  the  cellulose  wrap- 
pings of  its  grains  are  burst.  The  valuable  portion  of  a  food  is 
that  only  which  is  utilized  by  the  body.  The  proportion  of 
cellulose,  and  the  method  of  preparing  or  cooking  a  food,  must 
be  considered  in  judging  the  value  of  a  food  of  plant  origin. 

Fat  of  vegetable  origin  is  not  digested  in  the  body  so  readily 
and  well  as  that  of  animal  origin.  A  large  proportion  of  olive 
oil  and  other  kinds  of  vegetable  oils  passes  through  the  whole 
length  of  the  intestine  unchanged  when  considerable  amounts 
are  fed.  This  effect  may  often  be  desirable,  but  the  vegetable 
oils  are  to  be  considered  medicines  rather  than  foods.  The  prin- 
cipal source  of  fat  must  be  food  of  animal  origin. 

Utilization  of  Building  Foods.— The  digestion  of  a  protein 
consists  principally  in  its  reduction  to  amino-acids;  and  its  as- 
similation consists  in  building  the  amino-acids  into  the  proteins 
which  exist  in  the  body.  About  eighteen  kinds  of  amino-acids 
are  required  to  maintain  the  body  in  health.  The  protein  of 
each  kind  of  food  is  composed  of  particular  amino-acids.  If 
there  are  more  of  any  kind  than  the  body  needs,  the  excess  will 
be  wasted,  and  their  presence  in  the  blood  or  intestine  may  be 
a  source  of  trouble.  What  is  called  indigestion  is  often  due  to 
an  excess  of  unused  products  of  digestion,  and  may  be  remedied 
by  a  proper  combination  of  food  which  will  supply  the  various 
amino-acids  without  an  excess  or  deficiency  of  any. 

If  there  is  a  deficiency  of  any  kind  of  amino-acid,  the  nutri- 
tion of  the  body  will  suffer.  If  there  is  a  lack  of  a  single  element 
that  is  normally  present  in  the  body,  growth  and  repair  will 


394  THE   HEALTH    OFFICER 

cease,  just  as  the  lack  of  a  certain  kind  of  nails  may  prevent  the 
erection  of  a  buikling.  If  a  diet  is  delicicnt  in  an  amino-acid, 
the  addition  of  that  acid  may  enable  growth  and  repair  to  pro- 
ceed at  a  rapid  rate.  New  discoveries  regarding  specific  protein 
deficiency  are  constantly  being  made  as  the  result  of  experiments 
in  feeding  domestic  animals.  They  shed  light  on  the  causation 
of  rickets,  scurs'y,  and  the  malnutrition  of  infants  fed  on  con- 
densed milk  and  patent  foods. 

A  great  problem  in  feeding  is  to  choose  such  a  combination 
of  foods  that  the  quantity  of  the  various  amino-acids  will  exactly 
meet  the  needs  of  the  body.  Two  broad  principles  underlying 
the  choice  are  now  recognized. 

1.  About  one-fifth  of  the  protein  of  food  must  be  of  animal 
origin.  It  may  be  meat,  or  milk,  or  dairy  products,  or  eggs,  or 
fish,  or  shell-tish,  or  any  other  kind  of  animal  food. 

2.  A  variety  of  food  is  necessary  in  order  to  insure  a  supply 
of  all  the  various  amino-acids  that  are  needed.  There  need  not 
be  a  variety  at  each  meal,  or  even  each  day,  for  there  are  great 
reasons  for  having  only  two  or  three  dishes  at  a  meal;  but  a 
monotonous  diet  of  a  very  few  things  can  seldom  be  kept  up  for 
many  weeks  at  a  time  without  impairment  of  growth  and  nutri- 
tion. A  variety  is  especially  desirable  for  those  children  who 
from  choice  or  force  eat  only  one  or  two  articles  of  food. 

Regulative  Foods. — The  regulative  food  elements  are  those 
which  supply  little  or  no  material  for  fuel  or  building,  and  yet 
are  absolutely  necessary  for  growth  and  repair,  and  for  main- 
taining the  body  in  health  and  vigor.  They  consist  of  mineral 
salts  and  vitamins.  The  bulk,  or  volume,  of  a  food,  and  its 
taste  are  also  elements  which  have  a  regulative  effect  on  the 
nutrition  of  the  body. 

Inorganic  Mineral  Salts. — The  inorganic  salts  are  the  sub- 
stances which  are  left  as  ashes  when  a  food  is  burned.  They 
have  at  least  three  important  uses:  1,  they  maintain  the  alka- 
linity of  the  blood  (page  387);  2,  they  supply  building  material 
for  all  the  tissues,  particularly  the  bones  and  teeth;  and  3,  their 
presence  is  necessary  for  the  action  of  the  heart  and  for  nerve 
activity.  A  deficiency  of  foods  containing  the  salts  is  an  ele- 
ment in  the  cause  of  scurvy. 

The  mineral  salts  must  be  in  the  form  of  their  natural  com- 
binations wnth  other  food  elements.  If  a  food  is  deficient  in 
them,  the  addition  of  the  ashes  of  a  food  will  not  supply  the  body 
with  the  missing  elements.  Some  are  found  in  nearly  all  natural 
foods,  but  they  are  present  in  the  proper  forms  and  proportion 
in  milk.  They  are  also  especially  abundant  in  juicy  fruits, 
leafy  vegetables,  and  salads.     Some  of  these  articles  of  diet  are 


FOOD    VALUES  395 

necessary  in  order  to  supply  an  abundance  of  inorganic  salts. 
There  seems  to  be  no  danger  in  taking  foods  containing  an  ex- 
cess of  the  salts. 

Vitamins. — The  vitamins  have  become  known  chiefly  from 
feeding  experiments  on  animals.  They  exist  in  only  minute 
quantities  in  any  food.  Their  chemical  composition  seems  to  be 
similar  to  that  of  a  protein.  Their  presence  cannot  be  detected 
by  a  chemical  analysis,  and  they  are  known  only  by  their  effects. 
If  a  diet  that  is  perfect  except  that  it  has  no  vitamins  is  fed  to 
young  animals,  the  animals  do  not  grow,  but  if  the  vitamins  are 
added,  growth  becomes  normal  at  once. 

If  an  adult  animal  is  fed  on  a  diet  free  from  vitamins,  it  slowly 
becomes  weak  and  diseased,  and  finally  dies. 

There  are  two  vitamins— one,  called  A,  is  soluble  in  fats, 
and  the  other,  called  B,  is  soluble  in  water. 

The  fat-soluble  vitamin.  A,  is  abundant  in  milk,  butter,  and 
cheese;  in  the  yolks  of  eggs;  in  Kvers  and  kidneys;  and  in  the 
leafy  vegetables,  greens,  and  salads.  It  is  less  abundant  in 
muscular  tissue  or  lean  meat.  Its  quantity  is  deficient  in  ce- 
reals and  potatoes.  It  is  almost  absent  in  peas  and  beans,  and 
is  entirely  absent  in  lard,  tallow,  and  the  vegetable  fats.  The 
effects  of  its  absence  from  the  diet  of  lower  animals  are  a  cessa- 
tion of  growth,  progressive  weakness,  and  death.  A  growing 
child  needs  milk,  butter,  and  eggs  in  order  to  obtain  an  abun- 
dance of  this  vitamin.  The  good  effects  of  cod-liver  oil  upon 
poorly  nourished  children  is  probably  due  to  its  content  of  fat- 
soluble  vitamin,  but  cod-liver  oil  is  no  better  than  butter  in  that 
respect.  Children  who  are  poorly  nourished  are  greatly  bene- 
fitted by  fresh  milk  and  eggs  on  account  of  their  content  of  the 
fat-soluble  vitamin.  A  lesser  proportion  of  this  vitamin  is 
required  by  adults  than  by  children;  but  adults  require  an  extra 
amount  after  a  wasting  illness  in  order  to  stimulate  the  produc- 
tion of  lost  tissue. 

Alfalfa  contains  the  fat-soluble  vitamin  in  large  proportions, 
and  on  this  account  it  has  a  high  value  in  promoting  the  growth 
of  domestic  animals.  Alfalfa  flour  also  has  a  considerable  pro- 
portion of  protein  and  carbohydrates,  and  can  be  readily  digested 
by  human  beings.  Almost  the  only  hindrance  to  its  use  in  bread 
is  its  bitter  taste.  The  development  of  a  variety  of  alfalfa  that 
is  palatable  to  human  beings  would  be  a  great  achievement  in 
human  feeding. 

The  water-soluble  vitamin,  B,  is  widely  distributed  through 
most  common  foods,  but  it  is  deficient  in  some.  It  is  abundant 
in  seeds  and  cereals,  but  it  is  unevenly  distributed  through  each 
individual  kernel.     It  is  absent  from  the  interior  of  a  kernel. 


396  THE  HEALTH   OFFICER 

but  is  concentrated  in  the  layer  just  beneath  the  outer  husk. 
The  rice  and  hominy  which  is  commonly  sold  in  stores  is  what  is 
called  polished,  meaning  that  the  husk  and  outer  layer  of  each 
kernel  has  been  removed  by  friction.  When  polished  rice  is 
the  principal  article  of  diet,  those  who  eat  it  are  subject  to  a 
fatal  form  of  neuritis  called  beriberi,  but  if  a  patient  eats  the 
whole  kernels,  or  drinks  the  water  in  which  the  whole  kernels 
have  been  soaked,  he  quickly  recovers. 

The  concentration  of  the  water-soluble  vitamin  on  the  outer 
layers  of  grain  kernels  is  one  of  the  principal  arguments  for  the 
use  of  unpolished  rice  and  hominy,  and  of  flour  made  from 
whole  wheat.  Another  argument  for  the  use  of  the  whole  grain 
is  that  protein  and  mineral  salts  are  also  more  abundant  in  the 
outer  layers  than  in  the  interior  of  the  kernel.  There  is  not  a 
great  difference  in  composition  between  whole  wheat  flour  and 
the  white  flour  made  from  the  interior  portion  of  the  wheat 
grains.  The  difl^erence  can  scarcely  be  noticed  when  a  varied 
diet  is  eaten,  but  the  deficiency  in  the  vitamin  may  lead  to  poor 
nutrition  when  white  bread  is  the  principal  article  of  diet. 

Neither  of  the  vitamins  are  affected  by  ordinary  cooking. 
Boiled  greens  and  cooked  dairy  products  will  supply  them  in  as 
good  form  as  raw  salads  and  fresh  milk. 

Bulky  Foods. — Foods  that  contain  considerable  indigestible 
matter  have  two  important  uses.  In  the  first  place  they  assist 
the  process  of  digestion  by  distending  the  intestine  and  helping 
the  flow  of  food  along  the  digestive  tube.  A  cow  needs  coarse 
food,  such  as  hay  and  straw,  for  its  digestive  tube  is  large  and 
its  intestinal  muscles  require  a  considerable  amount  of  substance 
on  which  to  act.  A  dog  has  a  small  intestine  that  is  adapted 
to  a  diet  of  meat  and  other  concentrated  foods.  The  plan  of 
the  intestine  of  man  is  intermediate  between  that  of  the  cow  and 
of  the  dog.  Man  requires  some  bulky  food  which  is  supplied 
by  such  foods  as  fruit,  the  green  garden  vegetables,  and  the 
coarse  coverings  of  the  kernels  of  grain. 

A  second  use  of  bulky  foods  is  to  satisfy  the  appetite  without 
exceeding  the  oxidizing  capacity  of  the  bqdy.  The  feeling  of 
hunger  is  satisfied  when  the  stomach  is  filled  with  tasty  food. 
A  stout  person  will  thrive  on  coarse  food  which  satisfies  hunger 
without  supplying  an  excess  of  fuel  or  building  food. 

Taste  and  Enjoyment  of  Food. — The  pleasant  taste  of  food 
is  important  in  promoting  its  digestion  and  assimilation.  When 
a  food  is  put  into  the  stomach  without  the  person's  knowledge, 
the  digestive  juices  do  not  flow,  and  the  muscles  of  the  digestive 
tract  are  slow  in  their  actions;  but  the  sight  or  smell  of  pleasant 
food  causes  the  digestive  juices  to  flow  and  the  muscles  to  act 


FOOD    VALUES  397 

even  when  the  stomach  is  empty.  We  need  such  tasty  foods  as 
juicy  fruits,  turnips,  cabbage,  and  cheese  in  order  to  promote 
digestion. 

Racial  habits  of  eating  and  individual  preferences  must  be 
considered  in  dieting. 

The  body  demands  a  variety  of  food  in  order  to  obtain  all 
the  necessary  food  elements,  especially  the  vitamins;  but  the 
variety  need  not  be  great  at  each  individual  meal.  There  may 
even  be  a  grave  objection  to  having  a  variety  at  every  meal. 
A  person  eating  a  dinner  of  many  courses  satisfies  several  ap- 
petities.  If  he  eats  hearty  soup,  and  a  fish  course  with  bread, 
he  obtains  about  all  the  protein  and  fuel  food  that  he  needs. 
His  appetite  for  soup,  fish,  and  bread  is  satisfied,  and  he  desires 
no  more  of  them  at  that  meal.  This  satisfaction  of  his  appetite 
is  a  sign  that  the  need  of  his  body  for  fuel  and  building  food  is 
satisfied.  But  when  he  sees  the  meat  course,  the  chicken,  and 
finally  the  dessert,  he  has  a  new  appetite  for  each;  and  if  he  takes 
them,  he  satisfies  a  number  of  appetites,  and  eats  too  much  of 
all  kinds  of  foods,  especially  the  proteins.  An  excellent  rule  is 
to  make  a  meal  out  of  only  two  or  three  kinds  of  food,  and  to 
vary  them  from  meal  to  meal. 

Our  appetites  and  tastes  are  given  to  us  in  order  that  we  may 
judge  what  foods  to  choose.  They  are  reliable  guides  if  we  do 
not  have  a  great  variety  of  foods  at  any  one  meal.  We  are 
usually  safe  in  satisfying  an  appetite  for  any  two  or  three  things 
at  a  meal.  Our  natural  appetites  will  usually  lead  us  to  choose 
the  foods  which  our  bodies  require. 

Choosing  a  Bill  of  Fare. — One  of  the  first  objects  to  be  con- 
sidered in  choosing  a  bill  of  fare  is  to  satisfy  the  peculiar  taste 
and  desires  of  the  person  who  eats  the  food.  Certain  national- 
ities and  certain  families  prefer  their  own  peculiar  dishes.  It  is 
usually  possible  to  satisfy  individual  preferences  and  yet  supply 
a  person  with  a  scientific  diet.  An  excess  or  deficiency  of  any 
element  in  one  dish  can  be  counteracted  by  another  dish  either 
at  the  same  meal  or  at  another. 

The  second  element  to  be  considered  in  a  bill  of  fare  is  to 
provide  the  proper  number  of  calories  produced  by  the  food. 
The  caloric  value  of  a  food  is  a  very  different  matter  from  its 
weight  or  volume.  Between  800  and  1600  calories  will  be  needed 
for  a  meal.  The  number  will  depend  principally  on  the  mus- 
cular activity  of  the  person  who  eats  the  meal. 

The  third  element  to  be  considered  is  to  include  a  proper 
quantity  of  protein.  A  person  requires  about  3  ounces  of  pro- 
tein daily,  or  1  ounce  at  each  meal.  After  choosing  foods  which 
yield  the  required  number  of  calories,  a  dietitian  will  estimate 


398  THE   HEALTH    OFFICER 

their  content  of  protein  or  building  material.  If  there  is  an 
excess  or  deficiency  of  protein,  it  may  be  corrected  by  changes 
in  the  kinds  of  foods  that  are  chosen.  It  is  a  good  rule  to  avoid 
two  dishes  rich  in  protein,  as,  for  example,  beefsteak  and  chicken 
at  the  same  meal.  A  common  fault  of  a  bill  of  fare  at  a  banquet 
is  its  great  excess  of  protein. 

A  dietitian  will  make  constant  use  of  tables  giving  the  com- 
position of  the  various  foods  and  the  calories  which  they  yield. 
It  is  not  necessary  that  every  meal  should  constitute  a  balanced 
diet.  A  few  meals  may  contain  an  excess  or  deficiency  of  an 
element,  provided  the  defect  is  corrected  within  a  week. 

A  fourth  element  to  be  considered  in  choosing  a  bill  of  fare 
is  to  include  the  proper  kind  and  amount  of  regulative  materials. 
If  there  are  children  to  be  fed,  nothing  can  take  the  place  of 
milk  or  other  dairy  products.  These  foods  are  the  best  sources 
of  the  fat-soluble  vitamin,  and  all  their  food  elements  are  in 
forms  which  are  readily  and  completely  utilized  by  the  body. 
Adults  require  fruits,  vegetables,  and  salads  on  account  of  their 
mineral  salts,  their  vitamins,  and  their  content  of  indigestible 
cellulose. 

A  balanced  ration  for  a  day  will  contain  at  least  one  article 
from  each  of  the  following  groups  of  foods: 

1.  Foods  rich  in  protein,  such  as  milk,  cheese,  meat,  fish, 
eggs,  beans,  or  peas. 

2.  Food  containing  starch  and  sugar  in  available  form,  such 
as  cereals  and  potatoes. 

3.  Foods  containing  animal  fats,  such  as  butter  and  fat  meat. 

4.  Foods  containing  mineral  salts  and  vitamins,  such  as 
fruitSj  fresh  vegetables,  greens,  and  salads. 


CHAPTER  XXXV 
SANITARY  ENGINEERING 

Public  health  work  may  be  divided  into  the  environmental 
and  the  personal.  The  original  work  was  principally  environ- 
mental, and  was  along  the  lines  that  are  now  known  as  sanitary 
engineering.  It  consisted  in  the  control  of  the  grosser  forms  of 
uncleanness,  and  embraced  such  activities  as  street  cleaning, 
plumbing  inspection,  the  removal  of  sewage  and  garbage  from 
public  sight,  the  improvement  of  grossly  polluted  water-sup- 
plies, and  the  abatement  of  offensive  nuisances.  These  activ- 
ities required  the  construction  of  extensive  public  works,  the 
supervision  of  laborers,  and  the  operation  of  mechanical  sys- 
tems. The  knowledge  and  skill  that  were  required  were  not 
those  of  a  physician  or  health  officer,  but  of  a  civil  engineer. 
The  profession  of  sanitary  engineering  is  now  recognized  as  co- 
ordinate with  that  of  medicine. 

The  work  of  the  sanitary  engineer  is  largely  the  mechanical 
removal  of  human  wastes,  and  their  purification  and  destruc- 
tion by  physical,  chemical,  and  biologic  means;  while  the  work 
of  the  physician  and  health  officer  is  principally  the  control  of 
human  beings  themselves  and  their  education  regarding  their 
personal  duties  in  preventing  diseases  and  promoting  health. 
A  health  officer  requires  the  assistance  of  a  sanitary  engineer 
as  frequently  as  that  of  a  medical  consultant  or  epidemiologist. 
Universities  give  the  degree  of  Doctor  of  Public  Health  in  sani- 
tary engineering  as  co-ordinate  with  the  same  degree  in  medi- 
cine. The  position  of  sanitary  engineer  ranks  with  that  of  an 
epidemiologist  in  the  knowledge  and  skill  that  are  required  and 
in  the  honor  that  is  associated  with  the  office.  One  of  the  most 
important  divisions  in  the  department  of  health  of  a  state  or 
city  is  that  of  sanitary  engineering.  It  is  necessary  for  a  health 
officer  to  be  familiar  with  the  scope  of  the  activities  of  a  sanitary 
engineer,  and  to  recognize  the  problems  that  are  to  be  referred 
to  him. 

Activities. — The  lines  of  public  health  work  which  are  under 
the  supervision  of  a  sanitary  engineer  are  as  follows: 

1.  Water-supphes. 

2.  Sewage  disposal. 

3.  The  pollution  of  streams  and  public  waters. 

399 


iOO  THE  HEALTH   OFFICER 

4.  Plumbing. 

5.  Garbage  disposal. 

6.  Drainage. 

7.  Nuisances. 

8.  Milk  pasteurization. 

9.  Ventilation  and  heating. 

10.  Lighting. 

11.  Housing. 

12.  Food  sanitation. 

13.  Industrial  hygiene. 

14.  Vital  statistics,  to  some  extent. 

15.  Sanitary  survey. 

Water-supplies. — Giving  advice  regarding  installing  and 
maintaining  public  supplies  of  pure  water  is  one  of  the  principal 
duties  of  a  sanitary  engineer.  A  health  officer  may  look  to  him 
for  instruction  regarding  the  following  points: 

1.  The  quantity  of  water  needed  and  the  amount  available. 

2.  Planning,  constructing,  and  maintaining  the  plant. 

3.  The  purity  of  the  water,  and  its  hability  to  future  con- 

tamination. 

4.  Its  adaptability  to  industries  (boilers,  laundries,  etc.). 

5.  A  sanitary  survey  of  the  watershed  or  source. 

6.  Cost  of  constructing  and  operating  the  plant. 

7.  The  conditions,  or  so-called  diseases,  which  render  water 

unwholesome  or  undesirable. 

8.  The  mechanical  operation  of  the  plants. 

9.  The  filtration  of  unsafe  water-supplies. 

10.  The  emergency  chlorination  of  water,  especially  during  an 
epidemic  of  a  water-borne  disease. 

Sewage  Disposal. — The  removal  of  household  water  after  it 
has  been  put  to  use  is  one  of  the  duties  of  a  sanitarj^  engineer. 
The  points  which  he  will  consider  are : 

1.  The  composition  of  the  sewage. 

2.  The  degree  of  puritication  that  is  needed. 

3.  Planning  and  constructing  sewer  S3-stems  and  disposal 

plants. 

4.  Operating  disposal  plants. 

5.  The  protection  of  water-supplies. 

6.  Organizing  sewer  districts. 

7.  Abating  nuisances  arising  from   sewage,   cesspools,   and 

privies. 
The  prevention  of  the  pollution  of  streams,  lakes,  and  other 
bodies  of  water  with  sewage  and  trade  wastes  is  a  problem  with 
which  a  sanitary  engineer  must  deal.     A  difficulty  in  its  solu- 
tion is  the  legal  plea  of  riparian  rights  of  those  who  pollute  the 


SANITARY   ENGINEERING  401 

water.  When  the  amount  of  foreign  material  was  comparatively 
small,  and  the  effects  of  the  pollution  were  not  appreciated,  the 
disposal  of  the  waste  substances  in  the  water  was  legal,  and  the 
use  of  the  water  for  disposal  purposes  had  a  financial  value. 
It  is  often  claimed  that  the  public  cannot  take  away  a  right  which 
has  been  legalized  by  years  of  usage.  New  York  State  met  the 
problem  in  1903  by  legalizing  the  existing  pollution  under 
certain  conditions,  but  forbidding  the  discharge  of  an  increased 
amount  of  polluting  material  (Public  Health  Law,  Section  76). 

The  supervision  and  inspection  of  plumbing  was  an  impor- 
tant duty  of  sanitary  engineers  and  health  officers  in  the  days 
when  the  fixtures  and  pipes  were  crude  and  their  working  prin- 
ciples were  not  understood.  Since  efficient  methods  of  construc- 
tion have  been  developed  and  the  fixtures  standardized,  plumb- 
ing has  become  a  minor  problem  in  public  health.  But  a  sani- 
tary engineer  must  give  particular  attention  to  the  plumbing  in 
designing  a  large  building  or  a  camp. 

The  protection  of  plumbing  against  freezing  has  an  impor- 
tant bearing  on  public  health.  An  epidemic  may  result  when  a 
spring  thaw  releases  a  large  amount  of  infectious  sewage  that  has 
flowed  upon  the  surface  from  a  frozen  waste-pipe. 

Garbage  Disposal. — The  disposal  of  garbage  in  cities  requires 
a  considerable  degree  of  engineering  skill.  Some  of  the  prob- 
lems which  a  sanitary  engineer  must  solve  are: 

1.  The  regular  collection  and  transportation  of  the  garbage. 

2.  The  recovery  of  grease  and  other  useful  substances. 

3.  The  suppression  of  fly-breeding  and  odors  at  the  reduction 

plants. 

4.  The  management  of  piggeries  in  which  the  garbage  is  used 

as  food. 

Drainage. — A  sanitary  engineer  is  often  required  to  do  drain- 
age work,  especially  for  the  prevention  of  mosquito  breeding. 
This  work  is  of  great  sanitary  importance  in  connection  with 
the  suppression  and  prevention  of  malaria  and  yellow  fever. 
It  is  also  of  economic  importance  in  the  vicinity  of  salt  marshes 
and  stagnant  swamps. 

Nuisances. — The  establishment  of  factories  and  transporta- 
tion lines  in  residential  districts  frequently  gives  rise  to  claims 
of  their  injurious  effects  on  health.  The  determination  of  many 
of  these  nuisances  is  a  matter  for  the  expert  knowledge  and  judg- 
ment of  a  sanitary  engineer.  The  rule  is  that  every  business 
must  be  conducted  with  due  regard  for  the  health  and  comfort 
of  other  persons.  Nuisances  are  often  supposed  to  be  insep- 
arable from  many  lines  of  business;  yet  it  is  possible  to  suppress 
the  nuisances  connected  with  most  occupations,  provided  the 
26 


402  THE   HEALTH    OFFICER 

cost  is  paid.  A  sanitary  engineer  is  the  expert  adviser  who 
devises  the  means  for  preventing  the  nuisances. 

The  common  nuisances  with  which  a  health  officer  deals  are 
under  the  control  of  the  division  of  sanitary  engineering  of  the 
state  department  of  health. 

Milk  Pasteurization. — The  pasteurization  of  milk  requires 
considerable  skill  in  the  manipulation  of  the  apparatus,  and  an 
expert  knowledge  of  mechanical  engineering.  The  supervision 
of  pasteurizing  plants  is  one  of  the  activities  of  a  sanitary  engi- 
neer. 

Ventilation  and  Heating. — The  ventilation  and  heating  of 
buildings  constitute  a  single  problem.  A  building  can  be  venti- 
lated readily  if  its  heating  is  disregarded;  or  kept  warm  easily 
if  ventilation  is  ignored.  Satisfactory  ventilation  and  heating 
depend  on  many  conditions  which  vary  in  buildings  that  are 
apparently  similar.  While  the  systems  are  somewhat  standard- 
ized, a  ready-made  one  that  works  well  in  one  building  may  be  a 
failure  in  a  similar  one  owing  to  differences  in  their  locations, 
prevailing  winds,  or  other  essential  conditions.  A  system  must 
be  adapted  to  the  particular  building  in  which  it  is  put.  Un- 
satisfactory \'entilation  and  heating  often  follow  a  failure  to 
employ  an  expert  sanitary  engineer  in  designing  and  construct- 
ing the  ventilating  and  heating  systems  of  large  buildings. 

Lighting. — The  lighting  of  schoolrooms,  lecture  halls,  fac- 
tories, and  other  assembly  places  is  a  problem  for  a  sanitary 
engineer.  Uneven  and  improper  lighting  produces  glares,  eye- 
strains, and  headaches,  and  is  a  great  contributing  cause  of 
fatigue.  A  competent  sanitary  engineer  can  arrange  the  lights 
so  that  a  room  is  illuminated  softly  and  evenly,  and  with  due 
regard  for  the  comfort  and  efficiency  of  its  occupants. 

Housing. — A  health  officer  frequently  has  housing  conditions 
brought  to  his  attention.  Among  those  which  affect  health  are 
the  following: 

Cubic  feet  of  space  per  person. 

Window^  area. 

Toilet  facilities. 

Water-supply. 

Plumbing. 

State  of  repair  of  the  rooms. 

Trades  and  occupations  followed  in  the  rooms. 

Rooms  in  the  building  used  for  immoral  purposes. 

Tliere  are  few  housing  laws  or  restrictions  except  in  the 
larger  cities,  although  there  is  a  great  need  for  them.  The 
housing  problems  that  come  before  a  health  officer  are  com- 
paratively simple,  and  the  remedies  are  usually  evident;  but  in 


SANITARY    ENGINEERING  403 

difficult  cases  the  source  from  which  the  health  officer  would 
seek  advice  is  the  division  of  sanitary  engineering  of  his  state 
department  of  health. 

Food  Sanitation. — The  supervision  and  control  of  food  sanita- 
tion in  homes,  stores,  and  eating  houses  is  within  the  scope  of 
the  knowledge  and  experience  of  the  average  health  officer,  but 
the  transportation  of  food  from  the  farm  to  the  retail  store, 
and  from  the  store  to  the  consumer  is  a  sanitary  engineering 
matter  which  has  an  important  effect  on  public  health.  The 
nutrition  and  activity  of  many  people  are  largely  dependent  on 
an  abundant  supply  of  food  at  moderate  cost  and  the  co-ordina- 
tion of  supply  and  demand  largely  through  proper  transporta- 
tion facilities.  Among  the  food  transportation  problems  which 
a  sanitary  engineer  will  aid  in  solving  are : 

1.  Providing  facilities  to  transport  food  supplies  from  areas 
of  abundance  to  places  of  scarcity. 

2.  Preservation  of  food  during  transportation. 

3.  Excessive  cost  of  transportation. 

4.  Duplication  of  delivery  routes,  as,  for  example,  a  dozen 
milk  wagons  delivering  milk  on  a  city  block  when  one  wagon  is 
sufficient. 

Industrial  Hygiene. — Accidents,  occupational  diseases,  and 
many  other  health  conditions  associated  with  trades  and  occu- 
pations frequently  come  to  the  attention  of  a  sanitary  engineer. 
Among  the  industrial  conditions  with  which  the  engineer  has  to 
deal  are  the  following: 

1.  The  collection  and  elimination  of  harmful  dust,  fumes, 

and  gases. 

2.  The  construction  of  guards  for  dangerous  machinery. 

3.  Devices  for  stopping  machinery  quickly  or  automatically 

in  case  of  accident. 

4.  The  substitution  of  machinery  for  hand  labor. 

Vital  Statistics. — A  sanitary  engineer  must  be  familiar  with 
th^  vital  statistics  of  his  district  in  order  to  know  the  diseases 
and  causes  of  death  with  which  he  has  to  deal.  A  number  of 
deaths  from  t3^hoid  fever,  for  example,  would  be  suggestive  of 
impurities  in  the  water-supply;  an  excess  of  pneumonia  cases 
would  require  an  investigation  into  housing  conditions;  and  an 
excess  of  industrial  accidents  and  occupational  diseases  would 
call  for  an  investigation  of  factory  conditions.' 

Sanitary  Survey. — One  of  the  duties  of  a  health  officer  is  to 
make  a  sanitary  survey  of  his  district  and  record  it  in  an  in- 
telligible manner.  If  he  does  this,  a  sanitary  engineer  can  read- 
ily obtain  the  elementary  data  which  he  can  use  in  his  work  in 
water-supplies,  sewage  disposal,  and  other  activities. 


404  THE   HEALTH    OFFICER 

Relation  to  Public  Health. — All  the  activities  of  a  sanitary 
engineer  have  an  effect  on  public  health  that  is  direct  and  im- 
mediate. Extensive  epidemics  have  been  caused  by  polluted 
drinking-water,  sewage  contamination,  deficient  drainage,  and 
unclean  milk-supplies.  The  suppression  of  the  great  public 
sources  of  infection  may  be  credited  to  sanitary  engineers.  But 
the  indirect  and  remote  effects  of  sanitary  engineering  are  also 
of  great  importance.  The  work  of  a  sanitary  engineer  may  be 
called  ci\-ic  housekeeping.  A  good  housewife  has  a  standard  of 
order  and  cleanliness  which  is  higher  than  that  which  is  required 
for  the  protection  of  the  health  of  her  family.  She  is  trained  to 
detect  unsanitary  conditions  in  their  incipiency,  and  to  correct 
them  before  they  develop  into  menaces  to  health.  The  condi- 
tion of  her  house  is  an  index  of  her  consideration  for  the  health 
and  comfort  of  her  family.  Civic  housekeeping  is  an  equally 
sure  indication  of  the  attitude  of  a  people  toward  public  health 
matters.  Public  carelessness  regarding  water-supplies,  sewage, 
garbage,  and  other  environmental  conditions  is  associated  with 
indifference  and  carelessness  in  all  matters  relating  to  public 
health;  and,  on  the  other  hand,  a  civic  pride  in  matters  of  sanita- 
tion and  public  decency  is  associated  with  a  high  standard  of 
public  health  in  all  its  phases. 

A  clean-up  week  campaign  affords  an  opportunity  for  a  health 
officer  to  apply  the  principles  of  sanitary  engineering  to  indi- 
vidual homes.  Heaps  of  refuse  and  filth  are  often  allowed  to 
accumulate  because  there  are  no  facilities  for  their  disposal. 
House-to-house  inspections  and  public  meetings  call  the  people's 
attention  to  the  need  of  co-operation  in  the  disposal  of  house- 
hold wastes.  The  activities  of  a  clean-up  week  are  frequently 
the  first  steps  which  lead  to  the  establishment  of  public  dump- 
ing grounds,  incinerators,  sewer  systems,  and  the  public  collec- 
tion of  garbage  and  rubbish. 

Relation  of  the  Health  Ofl&cer  to  the  Sanitary  Engineer. — 
Problems  in  sanitary  engineering,  like  those  in  epidemiology, 
vary  from  simple  conditions  for  which  the  ordinary  health  officer 
can  devise  a  remedy,  to  complex  problems  requiring  a  high  de- 
gree of  technical  skill.  A  health  officer  is  expected  to  be  edu- 
cated in  the  elementary  principles  of  sanitary  engineering  so 
that  he  may  recognize  the  existence  of  an  unsanitary  condition, 
diagnose  its  nature,  and  suggest  practical  means  by  which  it 
may  be  corrected.  If  an  unsanitary  condition  is  difficult  and 
complex,  he  will  refer  the  matter  to  the  engineering  division  of 
his  state  department  of  health.  His  further  duty  will  then  be  to 
promote  the  adoption  of  the  plans  for  the  correction  of  the 
condition.     Much  of  his  work  wiU  be  poHtical  in  obtaining  the 


SANITARY    ENGINEERING  405 

co-operation  of  his  board  of  health,  and  in  securing  a  favorable 
vote  for  the  plan  and  appropriation  when  the  matter  comes  up 
at  an  election. 

Relation  of  the  Sanitary  Engineer  to  the  Public  Health 
Laboratory. — The  natural  environment  of  the  fields  and  woods 
is  sanitary  and  healthful.  The  soil,  water,  and  air  are  naturally 
favorable  in  their  effects  on  human  health,  and  the  principal 
dangers  which  may  be  called  pubhc  are  those  from  wild  beasts, 
insects,  and  poisonous  plants.  Unhealthful  conditions  are  usu- 
ally of  human  origin,  and  the  first  ones  to  develop  when  a  dis- 
trict is  settled  are  the  pollution  of  water  with  human  excretions, 
and  the  introduction  of  insect-borne  diseases  such  as  typhus 
fever  and  malaria.  The  problem  of  a  sanitary  engineer  is  to 
keep  the  soil,  water,  and  air  of  a  settled  community  as  pure  as 
they  are  in  the  woods  and  open  fields.  He  must  detect  the 
polluting  material  before  it  is  evident  to  the  senses  or  produces  a 
disease.  He  can  do  this  by  means  of  chemical,  bacteriologic, 
and  biologic  analyses.  A  public  health  laboratory  is  a  neces- 
sary adjunct  to  the  office  of  a  sanitary  engineer.  The  special 
work  which  the  laboratory  will  do  for  the  sanitary  engineer  is 
the  examination  of  water,  sewage,  milk,  and  air,  and  the  identi- 
fication of  disease-bearing  insects. 

Legal  Duties. — ^A  sanitary  engineer  must  give  due  considera- 
tion to  the  legal  phases  of  his  work.  The  proof  of  the  existence 
of  unsanitary  conditions  which  are  not  evident  to  the  senses 
must  be  in  legal  form,  and  sufficient  to  convince  a  judge  or  jury 
if  the  matter  should  be  brought  to  court.  Laboratory  samples 
must  be  collected  by  competent  persons,  and  their  identity  in 
the  laboratory  estabhshed.  The  correction  of  many  unsanitary 
conditions,  the  estabhshment  of  water  and  sewer  districts,  and 
the  construction  of  public  works  must  all  be  done  strictly  ac- 
cording to  law.  A  sanitary  engineer  is  expected  to  advise  the 
health  officer  regarding  these  legal  matters,  and  to  see  that  all 
the  forms  of  law  are  observed. 


CHAPTER  XXXVI 

NUISANCES 

Conditions  and  things  which  affect  health  and  life  vary 
from  those  which  are  merely  annoying  to  those  which  are  deadly. 
Those  whose  influence  on  health  is  slight  or  imaginary  are  called 
nuisances. 

Progress  in  public  health  knowledge  has  led  to  great  changes 
in  the  subjects  on  which  emphasis  is  placed.  The  air  and  the 
ground  were  fonnerly  supposed  to  be  the  natural  breeding-places 
of  epidemics.  The  causes  of  disease  were  believed  to  be  the 
weather  and  the  soil  during  the  first  quarter  of  the  nineteenth 
century,  and  as  long  as  this  belief  in  uncontrollable  sources  of 
infection  prevailed,  there  could  be  no  science  of  preventive  medi- 
cine. The  development  of  the  science  of  bacteriology  during  the 
last  quarter  of  the  nineteenth  century  led  sanitarians  to  ascribe 
the  causes  of  disease  to  the  products  of  fermentation  and  decay, 
such  as  sew'er-gas,  emanations  from  decaying  matter,  and  filth 
of  all  kinds.  It  was  supposed  that  dirt  and  decaying  substances 
in  themselves  bred  diseases,  and  sanitarians,  therefore,  placed 
the  emphasis  of  public  health  work  on  outw^ard  cleanliness. 
Sewers  were  constructed,  modern  plumbing  was  installed,  and 
pure  w^ater-supplies  were  secured.  The  surroundings  and  en- 
vironments of  man  and  every  unclean  condition  were  supposed 
to  be  the  principal  causes  of  disease. 

Standards  and  opinions  w^hich  were  new  and  up  to  date  dur- 
ing the  last  quarter  of  the  nineteenth  century  are  now^  matters 
of  common  knowledge,  and  civic  cleanliness  is  as  much  expected 
as  personal  cleanliness,  and  the  popular  standards  in  both  are 
so  high  that  they  more  than  meet  the  requirements  of  public 
health.  Boards  of  health  and  health  officers  would  have  little 
to  do  if  public  health  work  consisted  principally  in  maintaining 
cleanliness,  for  plumbers  and  policemen  and  the  great  majority 
of  people  themseh'es  have  both  the  knowledge  and  the  desire 
to  make  their  environment  sanitary  to  such  a  degree  that 
further  efforts  in  that  direction  would  usually  have  only  a  minor 
effect  on  health. 

The  new  public  health  is  founded  on  the  principle  that  the 
source  of  communicable  diseases  is  man  himself,  and  that  things 
outside  of  the  human  body  are  dangerous  only  when  they  have 
406 


NUISANCES  407 

been  polluted  by  man  himself.  Dirt  and  decaying  substances 
are  seldom  dangerous  unless  they  come  from  man,  and  even  then 
they  are  not  dangerous  unless  the  person  from  whom  they  come 
has  a  communicable  disease.  This  new  conception  may  be  il- 
lustrated by  diphtheria.  The  principal  cause  of  diphtheria  was 
formerly  supposed  to  be  sewer-gas  and  other  emanations  from 
decaying  substances,  but  now  it  is  known  to  be  transmitted 
almost  entirely  by  direct  contact  of  a  person  with  one  who  car- 
ries the  germs. 

Influence  of  Environment. — The  importance  which  a  health 
officer  assigns  to  an  unpleasant  or  annoying  condition  is  often 
at  variance  with  that  which  the  public  ascribes  to  it,  for  the 
popular  behefs  regarding  hygiene  today  are  those  held  by  aver- 
age sanitarians  a  generation  ago.  One  of  the  most  troublesome 
problems  of  a  health  officer  is  how  to  make  a  complaining  public 
consider  the  things  of  man's  environment  in  their  true  relation 
to  health.  The  environmental  things  which  commonly  have  a 
major  effect  on  the  health  of  man  are  milk,  food,  water-supplies, 
sewage,  flies,  and  mosquitoes.  Most  other  things  in  man's 
environment  have  only  a  minor  effect  on  health,  and  are  nui- 
sances rather  than  poisons.  A  fair  estimate  is  that  90  per  cent, 
of  the  influences  which  affect  health  are  those  which  one  person 
has  upon  another,  and  only  10  per  cent,  are  those  of  the  environ- 
ment upon  man.  Sanitarians  no  longer  place  the  major  emphasis 
on  cleaning  up  the  environment  of  man.  Carting  away  rub- 
bish, ashes,  and  tin  cans,  disposing  of  waste-water  from  kitchen 
sinks,  and  suppressing  odors  from  pig-pens  and  hen  roosts  are 
spectacular  acts  which  produce  a  deep  effect  on  a  community, 
but  they  have  only  a  slight  effect  on  the  health  of  the  people. 
The  effective  protection  of  the  pubHc  depends  principally  on  a 
quiet  medical  inspection  and  supervision  of  individuals,  such 
as  the  discovery  of  diphtheria  carriers,  and  the  detection  of 
mild  cases  of  contagious  diseases.  There  is  nothing  spectacular 
or  sensational  in  this  work.  It  is  not  discussed  in  the  public 
press,  and  people,  judging  its  importance  by  the  publicity  given 
to  it,  often  rank  its  value  below  that  of  the  suppression  of 
nuisances  which  are  evident  to  the  eyes  and  noses  of  the  public. 
The  fact  that  a  skilled  health  officer  devotes  less  than  10  per 
cent,  of  his  time  and  energy  to  the  suppression  of  nuisances  does 
not  mean  that  he  is  neglecting  them.  Nuisances  are  now 
receiving  more  attention  from  departments  of  health  than  ever 
before,  and  the  comparatively  low  value  that  is  placed  upon 
their  suppression  is  due  to  an  increase  in  the  rating  of  the  direct 
influence  of  one  man  upon  another.  The  detection  and  suppres- 
sion of  nuisances  is  properly  the  work  of  unskilled  assistants  of 


408 


THE   HEALTH    OFFICER 


the  health  officer,  while  the  really  effective  work  of  protecting 
the  public  from  diseases  is  the  work  of  the  health  officer  himself 
and  of  his  expert  superiors. 

Definition  of  a  Nuisance. — A  great  difficulty  in  dealing  with 
nuisances  is  that  there  is  no  standard  definition  of  the  word. 
Blackstone's  delinition  is,  "That  which  worketh  hami,  injury,  or 
damage."  A  health  officer  may  consider  anything  to  be  a  nui- 
sance if  it  causes  sickness,  suffering,  or  annoyance;  but  there  can 
be  no  standards  of  what  constitutes  suffering  and  annoyance. 
Each  nuisance  must  be  considered  by  itself,  both  in  its  intrinsic 
importance  and  also  in  the  importance  which  is  popularly 
ascribed  to  it. 

The  law  recognizes  as  nuisances  many  things  and  conditions 
which  offend  customs,  decency,  or  morals,  or  are  damaging  to 
property  rights.  A  health  officer  is  concerned  only  with  those 
which  have  a  direct  effect  upon  health. 

How  Nuisances  Affect  Man. — The  nuisances  with  which  a 
health  officer  has  to  deal  may  be  divided  into  those  which  affect 
the  body  physically  and  those  which  affect  it  through  the  senses. 
Those  which  have  a  direct  physical  effect  upon  the  body  may  be 
divided  into  those  which  may  produce  a  communicable  disease, 
as,  for  example,  a  garbage  heap  containing  typhoid  germs;  and 
those  which  may  produce  a  non-contagious  sickness  by  chemical 
action,  as,  for  example,  irritating  gases  from  a  chemical  factory. 
Those  which  affect  the  body  through  the  senses  may  be  divided 
into  those  which  may  indirectly  produce  a  physical  effect,  as, 
for  example,  by  producing  loss  of  sleep  or  appetite,  and  those 
which  are  merely  anno3'ing.  The  manner  in  which  nuisances 
act  is  indicated  by  the  following  diagram: 


1.  Offend  customs,  decency,  or  morals. 


Nuisances.  < 


'  1.   Physically  and 
directly. 


2.  Affect  the  body.  • 


2.    Through      the 
senses. 


1.  Produce  a  communicable 

disease. 

2.  Produce  a  non-contagious 

sickness. 

1.  Produce  a  physical  effect 

indirectly,  as  by  loss 
of  sleep. 

2.  Cause  merely  an  annoy- 

ance. 


Bases  of  Classification. — A  health  officer  must  classify  nui- 
sances on  two  fundamental  bases:  first,  their  effect  on  health, 
and  second,  the  number  of  persons  aft'ected. 

Relation  to  Health. — Section  1530  of  the  Penal  Code  of  New 
York  State  calls  anything  a  public  nuisance  when  it  "Annoys, 


NUISANCES        '  409 

injures,  or  endangers  the  comfort,  repose,  health,  or  safety  of 
any  considerable  number  of  persons."  When  a  health  officer 
receives  a  complaint  of  a  nuisance,  his  first  problem  is  to  deter- 
mine whether  it  affects  health  or  not.  Some  nuisances  are 
always  dangerous  to  health;  some  may  be  dangerous  under 
certain  conditions;  and  others  do  injury  solely  on  account  of 
the  nervous  temperament  of  the  person  affected.  Whatever 
annoys,  injures,  or  endangers  the  comfort  and  repose  of  a  per- 
son may  injure  his  health  if  the  annoyance  is  considerable  in 
degree  and  is  continued  for  a  considerable  period  of  time.  The 
health  officer  must  usually  make  a  decision  whether  or  not  a 
nuisance  is  of  sufficient  importance  to  produce  an  effect  on  health. 
If  a  nuisance  does  not  affect  health,  the  health  officer  usually 
has  no  further  responsibility  concerning  it,  unless  the  law  or 
local  custom  places  it  under  his  jurisdiction.  A  health  officer 
is  expected  to  know  how  to  deal  with  every  kind  of  nuisance 
that  commonly  arises,  and  to  advise  both  the  complainants  and 
the  offenders  regarding  the  proper  action  to  take  in  abating  it. 
The  health  officer  of  a  rural  district  is  often  the  only  official 
to  whom  a  complainant  can  go.  If  he  refuses  to  discuss  an  evi- 
dent nuisance  which  does  not  come  directly  under  his  jurisdic- 
tion, the  nuisance  is  likely  to  go  unabated.  He  can  have  a  great 
influence  as  an  adviser  regarding  these  classes  of  nuisances. 

Nuisances  which  are  annoying  through  the  senses  are  often 
on  the  borderline  in  their  effect  on  health.  A  nuisance  which 
a  strong  laboring  man  would  disregard  may  cause  great  suffering 
to  a  refined,  dehcate  lady.  Nuisances  which  operate  through  the 
sense  of  sight  seldom  affect  health  or  come  under  the  jurisdiction 
of  a  health  ofiicer,  and  a  person  who  is  annoyed  by  them  can 
usually  avoid  them  readily.  Nuisances  which  operate  through 
the  senses  of  "^ smell  and  hearing  are  often  extremely  annoying. 
They  may  have  marked  effects  on  health,  and  a  person  who  comes 
within  the  range  of  their  influence  cannot  readily  escape  their 
effects.  The  principal  minor  nuisances  with  which  a  health 
ofl&cer  has  to  deal  are  odors  and  sounds. 

Public  and  Private  Nuisances. — Nuisances  are  also  classified 
as  pubHc  and  private.  A  pubhc  nuisance  is  one  that  may 
affect  a  considerable  number  of  persons,  as,  for  example,  the 
kitchen  drainage  from  a  house  in  which  there  is  a  case  of  t>^hoid 
fever.  This  drainage  might  affect  many  persons  even  if  it  is 
located  in  a  thinly  settled,  rural  district.  A  private  nuisance  is 
one  that  may  affect  only  a  few  persons,  as,  for  example,  a  hen- 
roost which  a  person  maintains  near  his  neighbor's  house  in  a 
thinly  settled  community.  The  roost  would  not  produce  a 
communicable  disease,  and  it  would  be  merely  an  anoyance  to 


410  THE   HEALTH    OFFICER 

only  one  family.  The  only  nuisances  in  which  a  health  officer 
is  authorized  to  act  officially  are  those  of  a  public  nature. 

If  a  health  officer  decides  that  he  cannot  act  on  a  nuisance 
because  it  does  not  affect  a  person's  health  to  a  degree  which  is 
evident  to  others,  or  because  it  affects  only  a  few  persons,  any- 
one who  is  affected  by  the  nuisance  may  bring  a  private  suit  to 
recover  damages  from  the  person  who  maintains  it. 

Nuisances  Per  Se. — When  a  health  officer  proceeds  to  abate 
a  nuisance,  he  must  usually  prove,  first,  that  a  certain  condition 
or  thing  exists,  and  second,  that  it  actually  constitutes  a  nuisance. 
But  there  are  some  things  and  conditions  of  which  a  court  will 
take  what  is  caWed  judicial  notice,  meaning  that,  if  the  condition 
or  thing  is  proved  to  exist,  the  court  will  consider  it  to  be  a 
nuisance  without  proof.  Those  conditions  and  things  which 
have  been  adjudged  to  be  dangerous  or  unlawful  under  all  cir- 
cumstances are  called  nuisances  per  se,  or  in  themselves. 

The  first  class  of  nuisances  per  se  is  composed  of  those  which 
are  universally  held  to  be  dangerous  both  by  experts  and  by  the 
public.  Examples  of  this  class  of  nuisances  are:  1,  a  glandered 
horse  watered  at  a  public  trough;  2,  diseased  meats  offered  for 
sale;  3,  dangerous  or  vicious  animals  kept  where  they  may 
endanger  the  public;  4,  oft'ensive  trades  conducted  in  a  public 
place;  5,  water  dammed  up  and  made  stagnant;  6,  drainage  from 
cesspools  flowing  into  a  stream  in  a  village;  and  7,  dead  anmials 
on  or  near  a  public  highway. 

A  second  class  of  nuisances  per  se  consists  of  those  which 
have  been  held  to  be  such  by  court  decisions.  An  example  is 
the  nuisance  of  dense  smoke. 

Nuisances  per  se  of  a  third  class  are  those  declared  to  be  such 
by  statute  law.  Examples  of  nuisances  of  this  class  in  New 
York  State  are  stagnant  water  in  which  mosquitoes  breed,  and 
depositing  noisome  substances  on  or  near  a  public  road. 

A  fourth  class  of  nuisances  per  se  are  those  which  exist  in 
violation  of  a  local  code  or  ordinance.  There  are  many  condi- 
tions and  things  about  which  there  is  usually  a  difference  of 
opinion  w^hether  or  not  they  constitute  nuisances,  and  a  health 
officer  is  often  in  doubt  whether  or  not  the  board  of  health  and 
public  opinion  will  sanction  his  attempts  to  abate  them.  If 
these  nuisances  are  specifically  mentioned  in  the  local  code, 
they  become  nuisances  per  se,  and  the  health  officer  may  pro- 
ceed against  the  offending  persons  on  the  ground  of  violating  a 
local  ordinance.  Moreover,  a  community  which  desires  to  have 
a  high  standard  of  civic  cleanliness  may  declare  almost  any 
undesirable  condition  to  be  a  nuisance  which  a  health  officer 
may  abate  without  proving  the  condition  to  be  detrimental  to 


NUISANCES  411 

health.  The  local  sanitary  code  of  a  community  often  deals 
with  conditions  which  public  opinion  holds  to  be  nuisances  in 
that  place,  and  which  may  not  be  considered  to  be  nuisances  in 
an  adjoining  town. 

Legalized  Nuisances. — There  are  trades  and  occupations  and 
branches  of  municipal  work  in  which  nuisances  cannot  be  avoided. 
Many  of  these  nuisances  are  legalized  by  decisions  of  the  courts 
or  by  statute  laws.  Examples  of  legalized  nuisances  are  rail- 
road trains  operated  at  night,  village  dumping  grounds,  garbage 
disposal  plants,  and  contagious  disease  hospitals.  The  rule  in 
these  cases  is  that  every  reasonable  attempt  shall  be  made  to 
render  the  nuisances  as  slight  as  possible.  But  even  if  a  nuisance 
is  legalized,  an  individual  may  maintain  a  private  suit  at  law  for 
damages.  This  principle  was  established  by  the  suits  brought 
against  the  elevated  railroads  of  New  York  City  for  damages 
caused  by  the  noise  of  the  trains  and  the  interference  with  the 
access  of  light  and  air  to  the  houses  adjoining  the  tracks. 

Necessary  Nuisances, — When  a  health  officer  investigates  a 
nuisance,  the  defense  is  often  made  that  it  cannot  be  helped. 
Examples  of  necessary  nuisances  are  livery  stables,  gas  houses, 
slaughter  houses,  iron  foundries,  and  noisy  factories,  especially 
those  located  in  villages  and  cities.  People  who  come  to  crowded 
centers  of  population  must  expect  to  find  the  nuisances  mul- 
tiplied as  well  as  the  conveniences,  for  noises,  odors,  and  dust 
accompany  the  advantage  of  easy  transportation,  accessible 
markets,  and  social  life.  The  noises  and  dust  which  accompany 
certain  trades  and  occupations  constitute  nuisances  which  must 
be  endured  if  factories  are  to  produce  the  modern  necessities  of 
life.  Necessary  nuisances  are  on  a  par  with  those  which  are 
legalized.  Many  of  them  would  be  nuisances  per  se  if  they  were 
maintained  in  a  residential  section  of  a  village  or  city,  but  they 
are  tolerated  when  the  people  who  live  near  them  are  workmen 
who  choose  to  live  near  their  places  of  work. 

Necessary  nuisances  are  by  no  means  beyond  the  control  of 
the  health  officer.  He  may  require  a  person  to  conduct  his 
business  with  a  due  regard  for  the  rights  of  others,  and  to  take 
all  reasonable  measures  to  prevent  his  business  from  becoming 
a  nuisance  to  anyone.  If  any  phase  of  a  necessary  business 
or  occupation  becomes  a  nuisance  as  a  result  of  neglect,  the 
offender  is  liable  to  punishment  for  maintaining  an  unnecessary 
nuisance. 

A  nuisance  is  not  to  be  excused  because  it  has  existed  for 
years  without  protest.  A  pig-pen  is  a  necessary  nuisance  on  a 
farm,  but  if  a  village  springs  up  around  a  barnyard,  the  farmer 
may  be  compelled  to  remove  his  pig-pens  and  stables.    He  can- 


412  THE   HEALTH    OFFICER 

not  maintain  them  on  the  ground  that  he  had  them  first  and  that 
hundreds  of  people  settled  around  him  voluntarily,  knowing  the 
condition  of  his  yard.  Every  new  regulation  of  a  board  of  health 
places  a  restriction  on  the  established  customs  of  some  persons, 
and  unwillingness  to  change  old  habits  does  not  excuse  anyone 
for  maintaining  what  a  majority  of  other  persons  consider  to  be 
a  nuisance. 

Lack  of  intention  to  annoy  anyone  is  no  valid  excuse  for 
escaping  the  penalty  of  maintaining  a  nuisance.  If  a  dog 
persistently  barks  through  the  night,  and  continually  annoys  a 
number  of  persons,  the  plea  of  the  owner  that  he  too  is  annoyed 
and  wishes  the  dog  would  keep  quiet,  does  not  excuse  him  from 
liability.  The  health  ofScer  may  require  the  owner  either  to 
keep  the  animal  quiet  or  to  get  rid  of  it. 

The  plea  of  unequal  damage  to  a  number  of  persons  does 
not  constitute  an  excuse  for  maintaining  a  nuisance  (New  York 
State  Penal  Code,  Section  1531).  Some  persons  are  not  an- 
noyed by  an  unpleasant  odor,  while  others  are  greatly  annoyed. 
If  a  nuisance  annoys  a  considerable  proportion  of  the  persons 
who  are  subject  to  its  influence,  a  health  officer  may  proceed 
against  the  offender. 

Kinds  of  Nuisances. — Nuisances  are  of  such  varied  nature 
that  any  classification  of  them  would  be  incomplete.  Those 
which  aft'ect  public  health  may  be  considered  under  twelve 
heads:  1,  decaying  matter;  2,  offensive  odors;  3,  drainage;  4, 
stream  pollution;  5,  stagnant  water;  6,  unsanitary  food  shops; 
7,  unnecessary  noises;  8,  smoke;  9,  dangerous  occupations;  10, 
diseased  animals;  11,  housing  conditions;  and  12,  public  con- 
veniences. 

Decaying  Matter. — Decaying  substances  are  considered  to 
be  nuisances  principally  because  they  are  offensive  to  the  senses. 
Almost  the  only  grounds  on  which  a  health  officer  may  consider 
them  to  be  harmful  to  health  is  that  they  may  be  the  breeding- 
places  for  flies  (page  329). 

Privies,  uncovered  cesspools,  and  other  incomplete  systems 
for  the  disposal  of  excretions  in  rural  districts  are  nearly  always 
offensive  nuisances  to  some  degree.  If  they  do  not  pollute 
water-supplies,  the  health  officer  will  usually  be  able  to  abate 
the  nuisance  connected  with  them  by  requiring  that  the  con- 
tents of  privies  shall  be  kept  covered  and  inaccessible  to  flies, 
and  that  sewage  shall  be  conducted  in  tight  plumbing  and  closed 
outdoor  pipes  to  its  final  disposal  place  under  ground. 

Garbage  is  in  a  class  with  sewage  when  it  contains  human 
excretions.  A  health  officer  may  properly  condemn  any  gar- 
bage heap  that  is  likely  to  undergo  decay  or  putrefaction,  or  is 


NUISANCES  413 

located  on  or  near  a  public  place  or  street.  The  refuse  of 
slaughter  houses,  butcher  shops,  and  fish  markets  comes  under 
the  jurisdiction  of  the  health  officer. 

Stables,  pig-pens,  and  hen-roosts  Contain  the  fermenting  ex- 
cretions of  animals.  If  these  excretions  were  dangerous  in 
themselves,  ordinary  milk  and  eggs  would  be  poisonous  foods. 
The  grounds  on  which  a  health  officer  may  control  stables,  pens, 
and  roosts  is  that  they  may  be  the  breeding-places  for  house- 
flies,  or  offensive  to  smell.  He  may  require  that  they  be  kept 
clean  and  dry.  A  board  of  health  may  establish  standards  of 
their  cleanliness.  It  may  specify  the  manner  and  frequency  of 
the  removal  of  their  contents,  and  may  require  the  use  of  sub- 
stances, such  as  borax,  which  will  prevent  flies  from  breeding. 
The  boards  of  health  of  some  cities  and  villages  are  allowed  by 
law  to  establish  restricted  areas  where  animals  and  chickens  may 
not  be  kept. 

A  health  officer  is  often  puzzled  over  the  disposal  of  the 
bodies  of  large  dead  animals  that  have  been  left  on  the  property 
of  some  one  not  their  owner.  The  rule  in  law  is  that  the  owner 
of  the  land  is  liable  for  any  nuisance  that  is  on  the  land.  If  the 
animal  is  on  a  pubhc  street,  the  health  officer  may  order  the  body 
buried  at  public  expense. 

Offensive  Odors. — The  gases  which  excite  offensive  odors  are 
popularly  supposed  to  be  deadly  emanations  and  nuisances 
which  produce  communicable  diseases.  Coal-gas,  illuminating 
gas,  and  the  gases  of  certain  chemicals,  such  as  chlorin,  may  be 
dangerous  to  health  or  life  because  of  their  direct  chemical  ac- 
tion when  they  are  inhaled  in  large  quantities;  but  there  is  no 
gas  that  can  produce  a  communicable  disease.  Gaseous  products 
of  decay  may  accumulate  in  a  closed  cesspool  in  such  quantity 
that  they  explode  when  a  lantern  is  lowered  into  the  pit,  but 
scavengers  who  breathe  the  offensive  gases  of  cesspools  in  a 
concentrated  form  are  not  subject  to  sickness  more  frequently 
than  other  persons.  The  leading  sanitarians  from  1880  to  1890 
taught  that  sewer-gas  would  cause  diphtheria  and  puerperal 
septicemia,  but  proof  was  soon  developed  that  it  did  not  con- 
tain the  specific  bacteria  of  the  diseases.  Sewer-gas  is  as  free 
from  bacteria  as  the  wind. 

The  principal  way  in  which  offensive  odors  affect  health  is 
through  the  mental  suggestion  of  their  origin.  They  are  often 
signs  of  decaying  matter  and  filth  which  are  not  to  be  tolerated 
in  any  community.  But  their  offensiveness  is  sufficient  grounds 
to  authorize  a  health  officer  to  take  action  to  suppress  them. 
A  health  officer  is  justified  in  suppressing  any  offensive  odor 
whether  it  comes  from  decaying  matter  or  not.     Examples  of 


414  THE   HEALTH    OFFICER 

such  odors  arc  those  from  soap  making,  chemical  fertilizers 
spread  near  dwellings,  and  hsh  markets  in  residential  districts. 

Offensive  Drainage. — The  drainage  of  dirty  water  and  offen- 
sive liquids  near  dwellings  or  in  public  places  is  rightly  con- 
sidered to  constitute  a  nuisance  with  which  a  health  officer  may 
deal.  Sewage,  the  overflow  from  cesspools,  and  the  drainage 
from  privies  are  obviously  dangerous,  for  they  contain  the  excre- 
tions from  human  beings.  The  drainage  from  kitchens  and 
laundries  is  on  the  borderline  of  danger,  for  it  may  some- 
times contain  small  amounts  of  human  excretions.  The  drain- 
age from  barnyards,  stables,  manure  piles,  and  slaughter  houses 
may  giN-e  rise  to  offensive  odors,  and  may  be  a  breeding-place 
for  flies.  The  question  sometimes  arises  whether  or  not  a  health 
oflScer  shall  consider  that  the  drainage  from  a  person's  house  or 
barn  upon  the  yard  of  another  constitutes  a  public  nuisance. 
He  is  safe  in  deciding  that  it  may,  for  infective  material  and 
flies  may  spread  to  considerable  distances,  even  if  the  odors  are 
local. 

Stream  Pollution. — The  pollution  of  streams  frequently  oc- 
curs both  by  the  natural  downhill  flow  of  surface  drainage  and 
also  by  the  wilful  use  of  streams  for  getting  rid  of  offensive 
material.  The  degree  of  off"ensiveness  and  danger  of  the  pollu- 
tion will  depend  on  several  factors.  If  the  drainage  contains 
sewage  or  other  human  excretions,  it  will  obviously  constitute 
a  nuisance  which  may  aft'ect  public  health.  Substances  which 
may  putrefy  also  constitute  public  nuisances  which  may  affect 
health.  Substances  which  merely  discolor  the  water  may  af- 
fect property  rights  only.  A  health  officer  must  also  consider 
the  eft'ect  of  the  foreign  substances  on  fish  and  plants,  and  the 
secondary  nuisance  which  may  result  from  their  death  and 
decay. 

The  danger  from  polluted  water  will  depend  also  on  the  uses 
to  which  the  water  is  put.  The  danger  will  obviously  be  great 
when  the  stream  is  used  as  a  source  of  water-supply,  or  for  har- 
vesting ice,  or  for  bathing,  or  for  watering  cattle.  The  relation 
between  the  amount  of  polluting  substances  and  the  quantity 
of  water  in  the  stream  must  also  be  considered.  Streams  polluted 
with  trade  wastes,  such  as  those  from  gas  works,  tanneries, 
and  paper  mills,  constitute  a  special  class  of  nuisances  which 
often  involve  damages  to  property  rather  than  to  health.  The 
intricate  legal  question  of  riparian  rights  is  often  invoked  when 
a  health  officer  tries  to  abate  the  pollution  of  a  stream. 

Stagnant  Water.— A  health  officer  frequently  receives  com- 
plaints about  stagnant  water  in  ponds,  marshes,  and  swamps, 
in  pools  formed  by  the  waste  water  of  ice  plants  and  other  fac- 


NUISANCES  415 

tories,  and  in  muddy  areas  of  marsh  land  recently  filled  in.  It 
is  popularly  believed  that  the  green  scum  which  often  forms  on 
stagnant  pools  is  detrimental  to  health.  The  scum  is  composed 
of  green  plants  which  absorb  carbon  dioxid  and  give  off  oxygen 
like  green  trees.  They  may  give  off  slight  odors  when  they  die. 
It  is  also  supposed  that  stagnant  water  gives  off  a  deadly  emana- 
tion, especially  at  night;  but  this  theory  has  been  disproved  by 
the  proof  that  malaria  is  caused  by  mosquitoes  which  breed  in 
stagnant  pools.  This  relation  of  mosquitoes  to  stagnant  water 
justifies  a  health  officer  in  considering  stagnant  water  to  be  a 
pubhc  nuisance.  The  nuisance  does  not  usually  consist  in  the 
water  itself,  but  in  the  mosquitoes  which  breed  in  the  water, 
and  the  action  which  a  health  officer  may  take  in  abating  the 
nuisance  is  directed  against  mosquitoes.  A  health  officer  may 
require  the  owner  to  cover  the  water  with  a  film  of  oil.  or  stock 
the  water  with  fish  which  will  eat  the  young  mosquitoes,  or  to 
abolish  the  water  altogether  if  there  are  no  practical  means  of 
preventing  mosquitoes  from  breeding  in  it. 

Sale  of  Food. — Local  health  departments  are  rightly  assum- 
ing more  and  more  control  over  food  stores,  such  as  bakeries, 
grocery  stores,  meat  markets,  candy  shops,  and  fish  stalls.  A 
health  officer  will  take  note  of  at  least  three  conditions  about 
them:  first,  their  cleanliness,  especially  of  their  ice-boxes  and 
cellars;  second,  protection  of  the  food  from  flies  and  other  ver- 
min; and  third,  the  exposure  of  the  food  to  street  dust,  flies,  and 
dogs  on  sidewalks  and  in  open  stalls. 

The  dishes,  cups,  and  spoons  in  which  ice-cream  and  soda 
water  and  other  soft  drinks  are  dispensed  may  be  contaminated 
with  the  mouth  discharges  of  persons  who  use  them,  unless  they 
are  sterilized  with  boiling  water.  A  local  health  board  may 
properly  require  the  owners  of  ice-cream  parlors  and  soda-water 
fountains  either  to  wash  the  used  utensils  in  boiling  water 
before  they  are  used  a  second  time,  or  to  use  paper  con- 
tainers and  spoons  which  are  to  be  discarded  after  being  used 
once. 

The  control  of  restaurants  might  well  be  assumed  by  local 
boards  of  health.  Minimum  requirements  are  that  kitchens, 
ice-boxes,  cellars,  and  store-rooms  shall  be  kept  clean;  that  flies 
be  excluded  from  the  kitchens  and  dining  rooms;  and  that  all 
dishes  shall  be  washed  in  boiling  water. 

There  is  great  need  for  educating  the  public  regarding  the 
sanitation  of  food  stores,  and  the  cleanliness  of  dishes  in  which 
foods  and  drinks  are  served  in  public  places.  A  health  officer 
cannot  enforce  high  sanitary  standards  in  the  sale  of  foods  and 
drinks  until  the  average  man  who  sits  on  a  jury  understands 


416  THE   HEALTH    OFFICER 

the  elementary  principles  of  the  transfer  of  infection  from  mouth 
to  mouth,  and  by  flies. 

Unnecessary  Noises. — Noises  affect  health  only  indirectly  by 
disturbing  comfort  and  repose,  especially  at  night  during  the 
hours  which  are  customarily  given  to  rest  and  sleep.  They 
are  usually  controlled  by  police  officers  on  the  ground  of  being 
a  disturbance  of  the  peace,  but  a  health  ofhcer  sometimes  re- 
ceives complaints  about  noises  and  requests  for  information 
how  they  may  be  controlled.  Some  of  the  noise  nuisances  which 
may  require  his  in\estigation  and  control  are  howling  dogs, 
crowing  roosters,  bellowing  cows,  the  exhausts  of  automobiles 
and  motor  boats,  whistles  and  bells,  flat  wheels  on  trolley  cars, 
and  noisy  occup^ations  in  a  residential  district.  A  noise  is  not  a 
public  nuisance  that  requires  action  by  a  health  officer  unless 
persons  from  several  different  families  are  affected  by  it. 

Smoke  consists  of  unburned  particles  of  carbon,  and  is  not 
directly  detrimental  to  health.  It  has  been  supposed  to  pro- 
duce tuberculosis,  but  coal-miners  are  no  more  subject  to  tuber- 
culosis than  workers  in  other  trades,  although  the  particles  of 
carbon  which  they  inhale  are  more  irritating  than  those  of  smoke. 
The  smoke  nuisance  with  which  a  health  officer  has  to  deal  is 
usually  a  private  one  and  afTects  only  a  few  persons  who  live 
immediately  beside  the  source  of  the  smoke.  The  proper  offi- 
cial body  to  deal  with  a  smoke  nuisance  is  the  board  which  has 
charge  of  the  ordinary  political  administration  of  a  community. 
A  health  officer  may  properly  act  in  an  advisory  capacity. 
Smoke  is  usually  caused  by  the  cooling  of  burning  gases  before 
they  are  completely  consumed,  and  it  may  usually  be  prevented 
by  proper  methods  of  feeding  and  firing  furnaces  and  boilers. 
The  smoke  of  boiling  tar  and  that  from  gas  plants  and  chemical 
works  may  contain  irritating  fumes  which  are  harmful  to  health, 
and  which  may  require  action  by  a  health  officer. 

Objectionable  Occupations. — Occupations  that  are  offen- 
sive or  dangerous  may  be  public  nuisances  with  which  a  health 
officer  has  to  deal  when  they  are  located  in  a  residential  dis- 
trict. Examples  of  this  class  of  occupations  are  duck  raising, 
slaughtering  animals,  fat  rendering,  soap  making,  fish-oil  extrac- 
tion, and  the  manufacture  of  explosives.  These  occupations 
are  necessary,  and  the  ground  of  calling  them  public  nuisances 
is  their  location.  The  objectionable  occupations  with  which  a 
health  officer  usually  has  to  deal  are  those  carried  on  by  individ- 
uals in  small  shops  in  their  own  back  yards. 

Diseased  Animals. — The  smaller  domestic  animals  which  are 
diseased,  especially  stray  cats  and  dogs,  may  be  public  nuisances 
which  may  affect  health.     Few  animal  diseases  may  be  com- 


NUISANCES  417 

municated  to  man,  but  dogs,  cats,  and  rabbits  may  have  rabies, 
and  cats  may  possibly  have  diphtheria.  A  health  officer  may 
properly  authorize  some  laborer  to  kill  and  bury  a  diseased 
animal  that  is  wandering  on  a  pubhc  street.  The  board  of  health 
may  properly  employ  a  dog  catcher  to  seize  and  kill  all  homeless 
dogs  and  cats,  and  it  is  the  duty  of  the  board  to  do  so  when  a 
case  of  rabies  is  found  in  a  community. 

Housing  Conditions. — Dwelling  houses  which  are  in  a  dilapi- 
dated condition,  or  which  lack  toilet  facilities  or  proper  drain- 
age, may  be  public  nuisances,  but  the  laws  are  inadequate  to 
enable  a  health  officer  to  improve  them  except  in  a  few  of  the 
larger  cities.  Every  state  has  need  for  definite  housing  laws 
which  will  enable  a  health  officer  to  prevent  persons  living  in 
unsanitary  houses,  and  to  condemn  dwellings  for  other  reasons 
than  that  they  harbor  the  germs  of  contagious  diseases. 

Public  Conveniences. — It  has  been  proved  that  bacteria  from 
the  mouth  adhere  to  the  edge  of  a  drinking-cup  that  has  been 
grasped  by  the  lips,  and  to  a  towel  on  which  the  lips  and  nose 
have  been  wiped.  Drinking-cups  and  towels  that  have  been 
used  in  common  by  several  persons  are  also  likely  to  convey 
disease  germs  from  one  person  to  another.  The  sanitary  code 
of  New  York  State  forbids  the  maintenance  of  common  drink- 
ing-cups and  towels  in  public  places  when  they  are  to  be  used 
by  more  than  one  person  without  being  adequately  cleansed. 
A  health  officer  may  consider  a  common  drinking-cup  or  com- 
mon towel  to  be  a  public  nuisance.  Pencils  that  are  distributed 
daily  to  scholars  in  a  school  promiscuously  also  constitute  a 
public  nuisance,  since  children  often  bite  them  and  wet  their 
points  with  their  lips. 

When  expectorated  matter  dries,  bacteria  from  the  mouth 
and  nose  may  rise  as  dust  and  be  inhaled  by  those  who  breathe 
the  dusty  air.  If  the  matter  dries  quickly,  the  bacteria  may 
remain  alive  in  the  dust.  Tubercle  bacilli,  streptococci,  and 
other  germs  of  infectious  diseases  may  be  found  alive  in  the  dust 
that  rises  from  expectorated  matter.  Spitting  on  floors  and 
sidewalks  in  a  public  place  constitutes  a  public  nuisance  which 
may  affect  health,  and  which  is  forbidden  by  many  sanitary 
codes.  Ordinary  spittoons  that  are  maintained  in  an  uncleanly 
state  may  also  be  considered  to  be  public  nuisances. 

A  health  officer  may  find  an  unclean  barber  or  his  shop  to 
be  a  public  nuisance.  Shaving  cups  and  brushes,  razors,  and 
hair  brushes  may  collect  bacteria  from  a  person  on  whom  they 
are  used.  An  instrument  may  pick  up  pus  germs  from  minute 
pimples  on  the  face  and  transfer  them  to  another  person.  The 
germs  of  ringworm  or  barber's  itch  may  be  thus  transferred. 
27 


418  THE    HEALTH    OFFICER 

The  sanitary  code  of  New  York  State  has  a  section  requiring 
barbers  to  cleanse  their  hands  and  instruments  before  serving 
their  customers. 

Investigation  of  a  Nuisance. — Custom  and  law  charge  the 
health  olliccr  with  the  control  of  nuisances  that  affect  health. 
He  must  act  whenever  an  alleged  nuisance  is  brought  to  his 
attention  either  by  a  complaining  citizen,  or  through  official 
inspection,  or  in  any  other  manner.  His  first  action  is  to  visit 
the  scene  of  the  supposed  nuisance  and  investigate  its  nature 
and  extent.  It  is  well  for  the  health  officer  to  take  written  notes 
on  the  spot,  describing  the  condition  exactly  and  taking  meas- 
urements and  samples  for  analysis,  if  necessary.  He  can  use 
the  notes  as  evidence  if  it  is  necessary  for  him  to  go  to  court  in 
abating  the  nuisance. 

A  health  officer  receives  many  complaints  that  are  the  out- 
come of  quarrels  between  neighbors,  and  on  investigation  finds 
that  the  conditions  of  which  complaint  is  made  are  not  much 
worse  than  the  average  in  that  locafity.  When  a  health  officer 
investigates  a  complaint,  it  is  well  for  him  to  investigate  the 
property  of  the  neighbors,  including  that  of  the  complainant, 
both  for  comparison  and  to  avoid  the  appearance  of  being 
partial.  If  one  nuisance  is  abated,  it  is  well  to  abate  all  similar 
nuisances  in  the  neighborhood  while  the  people  are  talking  about 
them. 

Decision.— The  second  duty  of  a  health  officer  is  to  render  a 
decision  based  upon  his  investigation.  The  possible  decisions 
that  he  might  make  are  indicated  in  the  following  scheme : 

1     If  violates  a  /  '^'^^  statute  law,  or 

1.  It  violates  a  j  ^^^  sanitary  code;  or 

2.  Affects  health  {  ^  ^^^  }  -<>  '^  ^  {  W  private"  }  """-«^  °' 

3.  Does  not  affect  health. 

A  health  officer  may  often  be  in  doubt  regarding  the  proper 
decision  to  make.  He  will  save  himself  and  his  board  much 
annoyance,  and  will  establish  a  reputation  for  wisdom  and  fair- 
ness, by  being  consistent  in  his  various  decisions,  and  by  making 
them  according  to  the  standards  of  the  community.  For  ex- 
ample, a  condition  which  would  be  regarded  as  an  intolerable 
nuisance  in  a  community  of  well-to-do  commuters  might  be  dis- 
regarded in  a  settlement  of  coal-miners. 

Action  to  he  Taken. — If  a  health  officer  finds  a  condition  which 
does  not  affect  health  or  which  constitutes  a  private  nuisance, 
he  will  have  no  further  official  connection  with  it;  but  he  may 
properly  give  advice  regarding  its  correction. 


NUISANCES  419 

If  a  public  nuisance  which  affects  health  is  found  to  exist, 
the  health  officer  must  take  immediate  action,  which  will  include 
the  following  four  steps: 

1.  Inform  the  party  against  whom  the  complaint  is  made  of 
the  decision. 

2.  Explain  to  him  the  exact  nature  of  the  nuisance. 

3.  Suggest  a  remedy  and  discuss  it  with  the  offending  party, 
or  with  his  plumber,  engineer,  or  other  expert  adviser,  if  neces- 
sary. 

4.  Obtain  an  answer  from  the  offender  whether  or  not  he 
will  abate  the  nuisance. 

The  formal  information  which  a  health  officer  gives  to  an 
offender  had  best  be  in  writing  so  that  no  excuse  can  be  made 
that  the  notice  had  not  been  given.  The  following  printed  form 
may  be  used  : 

Board  of  Health,  — 


(Place)  (Date)- 

Mr. 

A  condition  affecting  health  exists  on  your  premises  as  follows: 


You  are  advised  to  remedy  the  condition  within days. 

Signed — 


(Health  Officer). 

This  form  may  be  printed  with  stubs  on  which  the  health 
officer  may  keep  a  record  of  his  inspections  and  notices.  A 
supply  of  these  forms  bound  in  pads  is  a  necessary  part  of  a 
health  officer's  outfit.  When  an  offender  fails  to  abate  a  nui- 
sance, the  procedure  which  a  health  officer  is  to  follow  is  out- 
lined in  Chapter  VIII. 

A  health  officer  has  no  power  to  enforce  any  particular  method 
of  abating  a  nuisance.  If  he  should  order  a  particular  remedy, 
and  it  should  prove  to  be  insufficient,  the  offender  might  claim 
that  he  has  obeyed  the  order,  and  is  therefore  relieved  from 
further  Kability.  But  it  is  the  health  officer's  duty  to  give  an 
offender  advice  regarding  various  remedies  that  may  be  ap- 
plied, and  to  leave  the  decision  of  choosing  the  remedy  to  the 
owner.  For  example,  if  a  cesspool  is  overflowing,  it  would  be 
unwise  for  a  health  officer  to  order  the  installation  of  subsurface 
irrigation  pipes  from  the  cesspool,  but  it  would  be  his  duty  to 
advise  the  owner  of  that  and  of  other  methods  of  remedying  the 


420  THE   HEALTH   OFFICER 

condition,  and  to  indicate  the  comparative  value  of  the  various 
methods. 

Over  90  per  cent,  of  all  nuisances  are  remedied  by  offenders 
voluntarily  as  a  result  of  inspections  and  notices  given  by  health 
officers.  If  a  health  officer  is  sincere,  honest,  and  tactful,  he 
can  usually  persuade  an  offender  to  abate  a  nuisance.  If  an 
oflfendcr  is  angry  and  obstinate  on  the  first  visit  of  a  health 
officer,  he  will  usuall}-  calm  down  and  comply  with  the  advice 
after  he  has  thought  the  matter  over.  If  a  health  officer  is 
unable  to  persuade  an  offender  to  follow  his  suggestions  volun- 
tarily, he  has  three  means  of  enforcing  action:  first,  by  summary 
abatement;  second,  by  a  suit  at  law;  and  third,  by  an  order  of 
his  board  of  health. 

Summary  abatement  means  entering  upon  an  offender's 
property  and  abating  a  nuisance  at  public  expense.  The  New 
York  State  law  provides  that  the  cost  of  the  summary  abatement 
of  a  nuisance  may  be  recovered  from  the  owner  of  the  premises 
by  a  suit  at  law,  and  that  the  judgment  shall  constitute  a  first 
lien  upon  the  property.  It  also  authorizes  a  board  of  health  to 
use  public  funds  or  to  borrow  money,  if  necessary,  in  abating  a 
nuisance. 

The  method  of  summary  abatement  is  to  be  used  only  when 
the  danger  to  health  or  life  is  immediate  and  considerable.  Ex- 
amples of  nuisances  which  may  require  summary  abatement 
are  articles,  or  sewage,  or  drainage  which  are  known  to  contain 
disease  germs;  stray  dogs  which  are  vicious  or  rabid;  and  dead 
animals  on  property  whose  owners  are  unable  to  bury  them. 

It  is  the  intent  of  the  law  that  the  health  officer  shall  not 
abate  a  nuisance  summarily  except  on  the  order  of  his  board  of 
health,  for  the  power  is  too  wide  and  dangerous  to  be  entrusted 
to  one  person.  A  health  officer  who  employs  the  method  is 
personally  liable  for  the  costs,  and  also  for  possible  damages, 
unless  the  board  of  health  approves  his  action.  The  health 
officer  is  expected  to  use  the  method  on  his  own  initiative  only 
when  the  emergency  is  urgent. 

Suit  at  Law. — If  a  person  neglects  to  abate  a  nuisance,  the 
usual  method  of  compelling  him  to  act  is  a  suit  at  law.  This 
is  a  slow  method,  for  the  suit  is  usually  a  civil  action,  and  sev- 
eral days  must  elapse  between  the  ser\'ice  of  the  summons  and 
the  trial  of  the  case — in  New  York  State  at  least  six.  The 
direct  object  of  the  suit  is  to  recover  a  penalty,  but  the  effect 
of  a  suit  nearly  always  is  to  convince  the  offender  of  the  wisdom 
of  abating  the  nuisance. 

Injunction. — Another  court  proceeding  for  the  abatement  of 
a  nuisance  is  the  injunction.     An  injunction  is  an  order  of  a 


NUISANCES  421 

court  that  an  offender  shall  cease  from  doing  an  act  until  its 
legality  can  be  determined.  It  is  a  slow  and  costly  method, 
and  is  to  be  used  only  in  conditions  of  great  importance  when 
there  is  no  immediate  danger  to  health  or  hfe. 

All  court  proceedings  are  legal  actions  which  require  the 
assistance  of  a  lawyer.  A  health  officer  may  properly  refuse  to 
take  a  case  to  court  unless  the  board  of  health  will  employ  a 
lawyer  to  represent  him. 

Order  of  a  Board  of  Health. — A  third  legal  method  of  abat- 
ing a  nuisance  is  by  an  order  of  the  board  of  health  issued  after 
a  formal  investigation  of  the  condition.  The  members  of  the 
board  may  inspect  the  conditions  themselves  or  they  may  hold 
a  hearing  and  summon  witnesses.  The  board  makes  an  investi- 
gation, forms  a  judgment,  and  issues  a  notice  in  practically  the 
same  manner  that  a  health  officer  does.  The  principal  difference 
is  that  the  board  of  health  is  governed  by  the  rules  of  court  pro- 
ceedings, and  its  decisions  have  the  force  of  court  orders. 


CHAPTER  XXXVII 

THE  DISPOSAL  OF  HOUSEHOLD  WASTES 

Household  Wastes. — The  substances  which  are  discarded  as 
waste  matter  from  households  are  usually  classified  as  garbage, 
ashes,  and  rubbish.  Garbage  consists  of  substances  which  are 
likely  to  undergo  decay.  Ashes  and  rubbish  in  themselves  have 
no  bearing  on  public  health,  but  if  they  are  mixed  with  garbage, 
they  come  under  the  control  of  the  health  ofiicer. 

Decay. — One  of  the  principal  problems  with  which  a  health 
officer  has  to  deal  is  the  disposal  of  waste  matters  which  natu- 
rally decompose  into  harmful  or  ofi'ensive  substances.  These 
waste  matters  consist  of  dead  animals,  table  scraps,  meat,  slops, 
human  excretions,  filth,  grass,  manure,  and  all  other  wastes 
that  decay  or  rot.  The  decomposable  substances  are  dead 
materials  which  were  manufactured  by  living  things  out  of 
liquids,  gases,  and  minerals  that  are  found  in  the  soil  and  air. 
When  their  life  ceases,  a  process  called  decomposition,  or  decay, 
or  rotting  sets  in,  and  finally  returns  the  substances  to  the  soil 
and  air  in  their  original  forms  as  liquids,  minerals,  and  gases. 
Decay  is  necessary  in  order  that  life  may  continue,  for  it  unlocks 
the  substances  which  were  contained  in  living  things,  and  which 
would  otherwise  remain  bound  up  in  dead  substances  until  the 
earth  would  be  covered  with  dead  matter,  and  all  the  available 
food  substances  would  be  exhausted  from  the  soil  and  air. 

The  processes  of  decay  are  performed  principally  by  bac- 
teria, molds,  yeasts,  and  fungi.  They  or  their  spores  are  scat- 
tered everywhere  and  are  ready  to  grow  wherever  they  find  the 
proper  food.  Living  things  are  immune  to  the  organisms  of 
decay,  but  as  soon  as  a  living  substance  becomes  lifeless,  it  is 
susceptible  to  them  and  begins  to  decompose. 

The  bacteria  of  decay  may  be  divided  into  two  classes: 
first,  the  aerobes,  or  those  which  grow  in  the  presence  of  oxygen; 
and  second,  the  anaerobes,  or  those  that  grow  without  oxygen. 
The  substances  produced  by  anaerobic  bacteria  are  often  ex- 
tremely offensive,  and  the  process  by  which  they  are  produced 
is  called  putrefaction.  The  substances  produced  by  aerobic  bac- 
teria are  usually  only  mildly  oflfensive,  and  the  products  are  not 
likely  to  constitute  a  nuisance. 

Putrefaction  is  likely  to  take  place  when  a  mass  of  decaying 
substance  is  so  large  that  oxygen  cannot  readily  penetrate  every 
423 


THE    DISPOSAL    OF    HOUSEHOLD    WASTES  423 

part  of  it.  For  example,  a  pail  of  house  slops  will  soon  become 
putrid  and  offensive,  but  if  they  are  poured  upon  porous  soil, 
every  drop  comes  in  contact  with  oxygen,  and  the  decay  that 
takes  place  is  not  offensive.  A  dead  animal  undergoes  putre- 
faction because  oxygen  is  unable  to  penetrate  beneath  its  sur- 
face. Putrefying  substances  first  become  softened  and  then 
liquefied.  When  the  liquid  flows  away  or  soaks  into  the  soil,  it 
comes  in  contact  with  oxygen  and  then  is  acted  on  by  aerobic 
bacteria.  The  final  result  of  the  process  is  to  oxidize  the  decay- 
ing substance  and  to  change  it  to  the  same  substance  that  would 
be  formed  if  it  were  consumed  in  a  fire. 

Decomposition  of  Carbohydrates. — Decomposable  matter, 
like  living  things,  is  composed  of  three  classes  of  substances: 
first,  carbohydrates;  second,  fats;  and  third,  proteins.  Carbo- 
hydrates consist  of  sugars,  starches,  and  celluloses,  such  as  wood, 
cotton,  and  the  fibrous  parts  of  grass.  Sugars  and  starches  are 
decomposed  by  molds  and  yeasts  into  alcohol  and  carbon  dioxid ; 
and  by  bacteria  into  water  and  acids,  such  as  acetic  and  lactic 
acids.  Cellulose  is  decomposed  by  fungi,  molds,  and  bacteria, 
and  is  finally  changed  to  carbon  dioxid,  marsh  gas,  and  other 
simple  substances.  Cellulose  is  very  resistant  to  air-borne  bac- 
teria, but  it  is  readily  decomposed  by  the  organisms  which  are 
especially  abundant  in  the  soil,  and  this  fact  accounts  for  the 
rapid  decay  of  wood,  cotton,  and  other  forms  of  cellulose  when 
they  are  in  contact  with  the  ground.  Carbohydrates  do  not 
usually  decompose  to  offensive  and  harmful  products,  and  their 
disposal  seldom  gives  trouble  to  a  health  officer. 

Decomposition  of  Fats. — Fats  and  oils  are  very  resistant  to 
decay.  They  do  not  become  offensive  or  harmful  in  themselves, 
but  they  are  likely  to  clog  sewer  systems  and  prevent  the  dis- 
posal of  other  substances.  The  disposal  of  grease  in  waste- 
pipes  and  cesspools  is  often  a  difficult  problem  which  a  health 
officer  is  often  called  upon  to  solve.  It  is  probable  that  the 
greater  part  of  fatty  substances  which  reach  the  soil  are  eaten  by 
earthworms,  insects,  and  other  forms  of  animals. 

Decomposition  of  Proteins. — Protein  substances  undergo  de- 
composition and  decay  with  great  readiness.  The  decomposition 
is  usually  produced  by  bacteria,  but  also  by  fungi,  molds,  and 
yeasts.  If  the  decomposition  is  caused  by  anaerobic  bacteria, 
some  of  the  products  may  be  offensive  gases,  such  as  sulphu- 
reted  hydrogen  and  ammonia,  which  are  produced  through 
putrefaction.  If  the  decomposition  is  produced  by  aerobic 
bacteria,  the  substances  that  are  formed  during  the  course  of 
the  process  are  only  slightly  offensive.  Aerobic  bacteria  also 
cause  oxygen  to  unite  with  the  decomposing  substances,  and 


424  THE   HEALTH    OFFICER 

the  final  products  of  the  decomposition  are  carbon  dioxid,  water, 
nitrates,  sulphates,  and  other  completely  oxidized  substances. 
A  decomposition  that  begins  with  putrefaction  may  finally  end 
in  complete  oxidation  of  the  substance.  There  is  no  definite 
dividing  line  between  the  two  processes.  The  offensive  odors 
of  decaying  substances  come  principally  from  proteins.  The 
odors  from  proteins  of  animal  origin  are  usually  more  oft'ensive 
than  from  those  of  vegetable  origin. 

Products  of  Protein  Decomposition. — A  health  officer  is 
especially  interested  in  the  three  final  products  of  protein  de- 
composition— ammonia,  nitrites,  and  nitrates.  These  three 
substances  contain  the  nitrogen  of  the  protein.  Ammonia  is 
produced  in  comparatively  early  stages  of  decomposition,  and 
its  presence  indicates  that  active  decomposition  is  going  on. 
The  oxidation  of  ammonia  results  in  the  production  of  nitrites 
and  nitrates.  This  change  is  produced  by  nitrifying  bacteria 
which  are  abundant  in  the  soil,  especially  in  the  upper  few 
inches  where  air  has  ready  access.  The  ammonia  is  oxidized 
to  nitrites  and  then  to  nitrates.  The  nitrifying  bacteria  are  of 
great  importance  to  the  farmer  in  the  fertilization  of  the  soil, 
and  to  the  health  officer  in  the  disposal  of  household  wastes  and 
sewage.  The  disposal  of  household  wastes  in  rural  districts 
depends  largely  upon  the  nitrifying  bacteria  of  the  soil. 

Filtration. — When  a  liquid  containing  solid  particles  passes 
through  a  porous  substance,  such  as  the  soil,  the  sohd  particles 
are  held  back  while  the  liquid  passes  through.  This  process  is 
called  filtration.  The  proportion  of  suspended  solid  matter  that 
is  removed  from  the  liquid  will  depend  on  the  size  of  the  solid 
particles  and  of  the  pores  of  the  filter.  The  process  of  filtration 
will  not  remove  substances  that  are  dissolved  in  the  water. 

The  disposal  of  liquid  household  wastes  depends  upon  the 
co-ordinated  action  of  the  processes  of  filtration  and  nitrification. 
When  a  small  quantity  of  liquid  waste  is  thrown  upon  the  ground, 
it  filters  through  the  soil  slowly.  Its  solid  particles  are  held 
back  and  are  brought  into  contact  with  the  oxygen  of  the  soil 
and  with  the  nitrifying  bacteria.  The  substances  that  are  dis- 
solved in  the  liquid  are  also  acted  upon  by  the  oxygen  and  bac- 
teria, and  the  hquid  that  finally  reaches  the  deeper  layers  of  the 
soil  is  pure  water. 

The  processes  of  filtration,  oxidation,  and  nitrification  can- 
not go  on  constantly  and  with  no  interruption,  for  when  the 
ground  is  completely  soaked  with  waste  matter,  its  oxygen  is 
soon  exhausted  and  the  nitrifying  bacteria  cannot  act.  If 
household  waste  is  thrown  upon  one  spot  of  ground  frequently 
in  such  quantity  that  it  forms  a  pool,  little  or  no  purification  takes 


THE    DISPOSAL    OF    HOUSEHOLD    WASTES  425 

place.  But  the  solid  matters  which  are  filtered  out  lie  on  or 
near  the  surface  and  putrefy,  owing  to  the  absence  of  oxygen. 
Also  the  substances  that  are  dissolved  in  the  liquid  remain  un- 
changed and  are  likely  to  pass  down  through  the  deeper  layers 
of  the  soil  and  into  the  ground  water.  After  a  quantity  of  liquid 
has  been  emptied  upon  the  soil,  it  is  necessary  that  the  ground 
should  remain  unused  for  several  hours  in  order  to  allow  a  new 
supply  of  oxygen  to  penetrate  the  soil. 

Grass  and  plants  growing  in  the  soil  utilize  waste  substances 
as  food,  and  thus  promote  their  destruction. 

Source  of  Danger  from  Household  Wastes. — Decomposing 
wastes  of  houses  and  barnyards  may  be  harmful  to  health  for 
three  reasons:  first,  because  of  the  poisonous  products  of  their 
decomposition;  second,  because  they  may  contain  the  germs  of 
human  disease;  and  third,  because  of  their  relation  to  house-flies, 

Ptomains  and  other  liquid  or  solid  products  of  decomposition 
are  seldom  harmful  to  human  beings  unless  large  quantities 
reach  their  food-  or  water-supplies.  But  if  food  or  water  be- 
comes contaminated  with  decomposing  substances  in  sufficient 
quantities  to  do  harm,  they  would  be  so  offensive  to  smell  and 
taste  that  few  persons  would  use  them. 

All  manner  of  communicable  diseases  have  formerly  been 
ascribed  to  the  gases  of  decomposing  substances.  But  it  has 
been  proved  that  the  gases  do  no  harm.  Scavengers  who  inhale 
the  odors  in  concentrated  forms  do  not  have  communicable  dis- 
eases more  frequently  than  other  persons,  and  disease  germs 
are  not  found  in  the  air  of  places  that  are  filled  with  decaying 
substances.  The  ground  on  which  a  health  officer  may  condemn 
garbage  heaps  or  manure  piles  is  not  that  they  or  their  odors 
may  produce  disease,  but  that  they  are  annoying  to  those  who 
breathe  them,  and  that  they  may  be  the  breeding-places  of 
house-flies. 

The  principal  ground  on  which  a  health  officer  may  require 
the  proper  disposal  of  household  wastes  is  that  they  may  contain 
the  germs  of  human  disease.  A  health  officer  divides  decom- 
posable substances  into  two  classes — those  which  contain  human 
excretions  and  those  which  do  not.  The  excretions  from  nor- 
mal human  beings  are  not  more  harmful  than  those  from  lower 
animals,  but  excretions  from  those  who  are  diseased,  or  who  are 
carriers,  will  contain  the  germs  of  the  disease.  Any  collection 
of  household  waste  is  likely  to  receive  the  excretions  from  some- 
one who  is  discharging  disease  germs  from  the  body.  Since  the 
germs  in  excretions  are  surrounded  by  the  substance  in  which 
they  naturally  grow,  they  may  remain  aKve  for  a  considerable 
time  and  be  a  menace  to  those  who  live  near  them. 


426  THE    HEALTH    OFFICER 

The  two  methods  b}-  which  disease  germs  are  usually  trans- 
ported by  household  wastes  to  persons  are:  first,  by  means  of 
drinking-water  containing  drainage  from  the  wastes;  and,  sec- 
ond, by  means  of  house-flies.  The  principal  diseases  that  may 
be  spread  by  household  drainage  are  t\'phoid  fever  and  other 
intestinal  diseases.  Drinking-water  polluted  with  household 
wastes  was  the  cause  of  much  sickness  in  the  days  when  little 
care  was  taken  of  house  wastes,  and  when  open  springs  and  shal- 
low wells  were  the  usual  sources  of  drinking-water.  A  general 
clean-up  of  back  yards  and  the  proper  protection  of  water- 
supplies  has  reduced  the  amount  of  sickness  remarkably,  but  if 
a  considerable  number  of  people  in  a  town  should  return  to  the 
old  standards  of  the  disposal  of  wastes,  there  would  doubtless 
be  a  return  of  the  former  prevalence  of  sickness. 

House-flies. — One  of  the  greatest  arguments  for  the  proper 
disposal  of  household  wastes  is  that  house-flies  crawling  over 
them  may  pick  up  disease  germs  and  may  carry  them  to  food 
on  which  they  alight.  The  prevalence  of  t}^hoid  fever  and 
other  intestinal  diseases  to  a  greater  degree  in  summer  than  in 
winter  is  explained  by  the  presence  of  fly-carriers  in  sunmier. 
But  if  flies  could  find  no  human  excretions  on  which  to 
alight,  they  could  not  transmit  diseases  from  one  person  to 
another. 

Household  Wastes. — The  decomposable  household  wastes 
with  which  every  health  officer  has  to  deal  are:  1,  kitchen  drain- 
age; 2,  garbage;  3,  human  excretions.  These  waste  substances 
are  produced  in  all  dwelling  houses,  even  those  of  the  humblest 
and  most  ignorant  laborers.  Their  disposal  by  every  family  is 
done  according  to  some  system,  even  though  it  be  a  system 
adopted  merely  by  habit  or  convenience.  Inspections  of  these 
systems  and  giving  advice  regarding  their  control  are  among 
the  most  common  duties  which  every  rural  health  officer  has  to 
perform. 

Four  requirements  which  are  necessary  for  the  disposal  of 
household  wastes  are:  1,  that  they  shall  not  remain  exposed  on 
the  surface  of  the  ground;  2,  that  they  shall  be  placed  at  a  safe 
distance  from  a  dwelling  or  source  of  water-supply,  usually  at 
least  50  feet  distant;  3,  that  they  shall  be  protected  from  flies; 
and  4,  that  they  shall  be  kept  free  from  odors  or  other  objec- 
tionable features. 

These  requirements  may  be  met  in  extremely  simple  ways,  or 
costly  and  elaborate  systems  may  be  adopted.  Whatever  sys- 
tem is  adopted,  it  will  require  care;  but  the  attention  required 
is  no  more  than  the  poorest  and  most  ignorant  person  can  read- 
ily understand  and  give. 


THE    DISPOSAL    OF    HOUSEHOLD    WASTES  427 

Kitchen  Drainage. — In  ordinary  homes  where  no  plumbing 
exists  the  kitchen  is  the  place  where  all  the  members  of  the  family 
wash  their  faces  and  hands  and  do  their  laundry  work,  as  well 
as  wash  dishes  and  cook.  The  waste  water  from  these  kitchens 
will,  therefore,  contain  waste  matters  from  the  human  body. 
It  will  also  contain  much  protein  matter,  and  will  readily  de- 
compose and  putrefy.  If  a  member  of  the  family  has  a  com- 
municable disease,  the  kitchen  waste  water  may  contain  germs 
of  the  disease.  The  disposal  of  waste  water  from  kitchens 
properly  comes  under  the  supervision  of  the  health  oflficer. 

A  primitive  method  of  disposing  of  kitchen  drainage  is  to 
toss  it  out  of  doors  upon  the  ground.  This  may  be  sanitary  if 
the  quantity  is  so  small  and  scattered  that  it  soaks  into  the 
ground  at  once ;  but  it  is  not  sanitary  when  the  quantity  is  large 
or  when  the  ground  is  frozen.  If  a  pool  of  dirty  kitchen  water 
can  be  seen  around  the  kitchen  door,  the  health  officer  may 
properly  condemn  it. 

A  safe  method  of  disposing  of  kitchen  drainage  is  to  pour  it 
into  a  pail  and  to  empty  it  upon  the  back  part  of  the  yard,  first 
on  one  spot  and  then  on  another,  in  order  that  no  part  may 
receive  more  than  will  readily  soak  away. 

The  simplest  improvement  that  is  usually  installed  in  a 
kitchen  is  a  sink  with  a  waste-pipe  extending  through  the  side 
of  the  house  with  possibly  a  trough  or  pipe  extending  from  the 
house.  If  no  attention  is  given  to  the  system,  there  will  be  an 
offensive  pool  at  the  end  of  the  pipe.  Two  simple  remedies  for 
this  condition  are  to  have  a  movable  distributing  trough  and 
move  its  outer  end  daily  in  order  to  distribute  the  water  over  a 
large  area;  or  to  receive  the  water  in  a  pail  or  barrel  and  empty 
it  on  the  back  yard. 

A  so-called  improvement  that  is  often  attempted  is  to  con- 
duct the  water  into  a  headless  barrel  sunk  into  the  ground  form- 
ing a  tiny  cesspool.  This  contrivance  soon  becomes  clogged 
with  grease,  and  the  contents  become  putrid.  If  a  person 
cannot  afford  to  build  a  good-sized  cesspool,  he  had  better  have 
none  at  all,  but  use  pails  for  carrying  away  the  kitchen  waste 
by  hand. 

If  a  yard  is  small  and  is  in  a  congested  section  of  a  village,  a 
health  officer  may  properly  require  the  owner  to  build  a  large 
cesspool  to  receive  the  kitchen  drainage.  A  round  cesspool  4 
feet  in  diameter  and  4  or  5  feet  deep  is  large  enough  to  receive 
the  drainage  of  a  large  family.  It  is  desirable  to  have  also  a 
smaller  cesspool  to  receive  the  water  first  and  act  as  a  grease 
trap  in  order  to  remove  the  fatty  and  soapy  substances  before 
the  water  passes  into  the  main  cesspool.     It  is  necessary  to  place 


428  THE   HEALTH    OFFICER 

a  cover  on  a  cesspool  in  order  to  prevent  flies  and  mosquitoes 
from  entering  it  and  breeding. 

Garbage  consists  of  scraps  of  food  from  the  table,  and  kitchen 
refuse  such  ?.s  scraps  of  meat  and  potato  peelings.  It  also  con- 
tains oth&r  waste  substances,  such  as  dirty  papers,  boxes,  and 
tin  cans.  It  seldom  contains  disease  germs  or  has  a  direct 
effect  in  producing  diseases.  But  a  health  officer  is  justified  in 
supervising  its  disposal  because  it  may  ferment  and  become  the 
breeding-place  for  house-flies.  Ordinary  garbage  contains  a 
large  percentage  of  sugar  and  starch.  The  fermentation  of  the 
carbohydrates  produces  acetic  and  other  acids  which  restrain 
the  growth  of  anaerobic  bacteria  and  prevent  putrefaction. 
Garbage  seldom  putrefies,  but  it  readily  becomes  sour  and  gives 
off  a  peculiar  odor  which  is  offensive  to  most  persons. 

The  disposal  of  garbage  ought  not  to  be  a  difficult  problem 
for  a  rural  health  officer,  for  it  has  a  high  value  as  food  for 
animals,  and  householders  can  either  feed  it  to  their  own  animals 
or  they  can  usually  find  neighbors  who  will  take  it  away.  There 
is  no  excuse  for  throwing  it  on  an  ash  heap  in  the  back  yard 
since  anyone  can  dispose  of  it  properly  with  very  little  effort. 
If  only  a  small  quantity  is  produced,  it  may  be  buried  in  the  back 
yard  or  burned.  In  villages  it  may  be  collected  by  scavengers 
or  by  the  municipality  at  public  expense. 

The  laws  of  New  York  State  permit  the  formation  of  districts 
in  which  garbage  is  collected  at  public  ex-pense.  The  districts 
are  formed  by  petition,  as  a  sewer  or  lighting  district  is  formed 
(Town  Law,  Sec.  477a). 

Garbage  in  larger  cities  is  usually  collected  under  municipal 
control.  Grease  is  extracted  from  it,  and  the  residue  is  utilized 
as  fertilizer.  The  sale  of  these  two  products  often  meets  the  cost 
of  the  collection  and  treatment. 

Woodruff  Pit. — An  excellent  device  for  the  disposal  of  gar- 
bage is  the  Woodruff  pit.  This  consists  of  an  excavation  about 
12  feet  in  diameter  and  3  feet  deep,  whose  sides  are  lined  with 
brick  or  stone.  A  solid  mound  about  3  feet  high  is  built  in  its 
center,  leaving  a  circular  space  about  4  feet  wide  between  it 
and  the  side  walls  of  the  pit.  The  bottom  is  the  natural  soil. 
The  finished  pit  looks  like  a  shallow  cellar  with  a  mound  in  its 
center.  Garbage  and  rubbish  are  dumped  into  the  pit  and  set 
on  fire.  The  material  usually  contains  enough  boxes,  paper,  and 
other  combustible  substances  to  burn  the  whole  contents.  What 
is  not  burned  will  dry  out,  and  may  be  burned  a  day  or  two  later. 
The  ashes  may  be  removed  when  the  pit  becomes  partly  filled. 
A  pit  may  be  constructed  for  less  than  $100.  A  community 
may  construct  and  operate  one  at  public  expense. 


THE    DISPOSAL    OF    HOUSEHOLD    WASTES  429 

Human  excretions  consist  principally  of  proteins  that  are 
already  partly  decomposed.  They  readily  putrefy  and  produce 
the  same  kind  of  offensive  products  that  the  original  proteins 
produce  when  they  putrefy. 

Human  excretions  often  contain  disease  germs,  and  their 
disposal  is  one  of  the  most  important  problems  with  which  a 
health  ofhcer  has  to  deal.  The  lack  of  proper  disposal  of  human 
excretions  in  the  past  has  produced  more  sickness  and  a  greater 
number  of  deaths  than  almost  any  other  cause.  It  is  now  the 
principal  cause  of  hookworm  disease,  and  is  frequently  the  cause 
of  typhoid  fever.  It  is  also  one  of  the  principal  causes  of  the 
summer  diarrhea  of  infants. 

Disease  germs  are  transmitted  from  human  excretions  in 
three  principal  ways:  1,  by  water-supplies  containing  the  excre- 
tions; 2,  by  house-flies  which  have  alighted  on  the  excretions; 
and  3,  by  contact  of  persons  with  the  excretions.  The  danger 
from  contact  with  them  is  indicated  by  the  prevalence  of  hook- 
worm disease  in  those  parts  of  the  United  States  in  which  there 
are  few  provisions  for  the  disposal  of  human  excretions.  The 
young  hookworms  live  in  soil  polluted  by  the  excretions  and  gain 
access  to  the  body  through  the  skin  of  barefooted  persons. 

Privy. — The  most  common  method  of  disposing  of  human 
excretions  is  by  means  of  an  outdoor  water-closet  or  privy.  A 
health  officer  will  consider  the  following  points  in  judging  its 
sanitary  condition: 

1.  Location.  Is  it  located  where  its  contents  cannot  reach 
a  household  water-supply;  and  where  it  is  not  offensive  to  the 
senses  of  those  who  live  near  it? 

2.  Construction.  Does  it  confine  its  contents  so  that  they 
do  not  flow  over  the  surface  of  the  ground?  Is  it  tightly  en- 
closed against  house-flies?  Are  its  contents  readily  accessible 
for  removal? 

3.  Maintenance.  Is  it  maintained  in  a  decent,  odorless, 
and  sanitary  condition;  and  is  it  kept  in  repair? 

Location. — A  health  officer  frequently  has  to  decide  the 
question  of  the  proper  location  for  a  privy.  It  is  important  that 
a  privy  shall  be  located  on  the  downhill  side  of  a  dwelling  or 
source  of  water-supply  in  order  that  the  natural  flow  of  liquids 
shall  be  away  from  the  house  or  water-supply.  This  is  especially 
important  when  the  ground  is  frozen.  It  is  also  necessary  to 
consider  the  slope  of  underground  strata  of  rock  or  clay  in  order 
to  make  sure  that  they  do  not  incline  toward  the  water-supply. 

Locating  privies  so  that  they  are  not  offensive  to  the  sight 
or  smell  of  the  neighbors  is  one  of  the  most  common  problems 
of  a  health  officer.     It  is  frequently  a  practice  in  villages  for  a 


430  THE   HEALTH    OFFICER 

householder  to  place  the  privy  close  to  the  back  fence,  thus  bring- 
ing its  rear  opposite  a  neighbor's  kitchen.  This  is  a  matter  in 
which  a  health  officer  needs  definite  rules  and  regulations  of  his 
board  of  health  to  govern  his  decisions  and  actions. 

Constniction. — A  health  officer  who  condemns  a  privy  is 
often  asked  to  give  a  plan  for  a  privy  that  he  can  approve.  The 
following  are  the  specifications  for  a  sanitary  privy  of  the  mini- 
mum size:  The  building  is  3^  feet  square.  Its  front  is  7^  feet 
high,  and  its  rear  6tV  feet.  It  has  a  sloping  roof.  The  door  is 
28  inches  wide,  and  opens  outward.  The  seat  is  16  inches  high 
and  20  inches  wide.  The  hole  in  the  seat  is  8  x  10  inches.  A 
cover  for  the  opening  is  hinged  to  the  back  part  of  the  seat. 
The  rear  wall  of  the  building  is  cut  away  at  the  height  of  the  seat, 
and  is  made  into  a  door  which  may  be  opened  for  cleaning  the 
contents  of  the  receptacle. 

The  seat  and  the  rear  door  are  made  with  tight  joints,  and 
the  building  is  set  closely  upon  the  ground  or  upon  a  tight  raised 
foundation  in  order  to  exclude  ffies.  Tight  construction  of  the 
seat  and  back  is  a  most  important  point.  If  the  vault  is  dark, 
flies  are  not  likely  to  try  to  enter  it. 

An  excavation  a  foot  or  two  in  depth  is  made  under  the  seat 
to  receive  the  excretions.  If  it  is  too  deep,  the  contents  cannot 
be  easily  removed,  and  if  it  is  too  shallow,  they  overflow  upon  the 
ground.  An  elaborate  receptacle  consisting  of  a  water-tight  box 
of  cement  or  brick  may  be  built.  Its  disadvantage  is  the  difficulty 
of  removing  its  contents  in  a  sanitary  manner. 

It  is  desirable  that  the  privy  be  at  least  4|  feet  square  in 
order  that  the  door  may  open  inward.  It  is  also  desirable  that 
it  be  ventilated.  A  4-inch  ventilating  shaft  may  be  built  in  one 
corner,  extending  from  the  vault  up  through  the  roof.  It  is  also 
desirable  to  have  screened  windows  on  opposite  sides  of  the 
building. 

Earth  Closet. — A  pri\'y  is  least  objectionable  when  its  contents 
are  kept  dry.  A  simple  method  of  doing  this  is  to  keep  a  box 
of  dry  earth  or  ashes  in  the  privy  and  to  throw  a  shovelful  into 
the  vault  each  time  it  is  used.  This  is  an  imperfect  method, 
but  it  is  a  great  aid  in  lessening  the  offensiveness  of  the  excre- 
tions. An  ordinary  privy  cannot  be  kept  in  a  sanitary  condi- 
tion if  house  slops  are  emptied  into  it. 

Pail  System. — A  privy  in  which  the  excretions  are  received 
in  a  pail  or  can  is  a  great  improvement  over  one  in  which  they 
are  deposited  in  the  ground.  The  advantage  of  a  pail  recep- 
tacle is  that  it  is  easy  to  build  and  to  keep  clean,  and  that  the 
pails  may  be  readily  carried  away  without  danger  to  the  person 
who  handles  them.     The  disadvantage  is  that  it  requires  atten- 


THE    DISPOSAL    OF    HOUSEHOLD    WASTES  431 

tion  every  few  days.  The  pail  system  can  be  used  wherever 
ordinary  privies  are  used.  In  congested  sections  of  villages 
where  there  are  no  sewer  systems,  the  pail  system  with  municipal 
collections  is  almost  a  necessity  for  those  houses  which  are  not 
supplied  with  running  water  and  cesspools. 

The  privy  described  on  page  430  may  be  adapted  to  the 
pail  system  by  extending  the  floor  under  the  seat  and  placing  a 
can  or  pail  under  the  opening.  A  garbage  can  15  inches  in 
diameter  and  15  inches  high  makes  a  good  receptacle. 

Maintenance. — A  privy  requires  attention  like  everything 
else  that  is  in  constant  use.  It  requires  cleaning  at  least  as 
frequently  as  its  receptacle  is  filled  to  the  surface  of  the  ground. 
A  flimsy  building  soon  falls  to  pieces,  and  a  health  officer  must 
decide  whether  or  not  it  is  fly-proof  and  tight.  A  tenant  moves 
out  and  leaves  the  receptacle  full,  and  the  health  officer  is  then 
called  to  determine  whether  the  landlord  or  the  tenant  shall  clean 
it.  These  are  largely  legal  questions  which  a  belhgerent  house- 
holder may  contest  in  court.  A  health  officer's  success  in  secur- 
ing the  proper  maintenance  of  the  privies  in  his  jurisdiction  will 
depend  largely  on  the  standards  which  the  board  of  health  speci- 
fies in  its  rules  and  regulations. 

The  removal  of  the  contents  of  privies  is  a  troublesome  prob- 
lem in  villages.  There  is  difficulty  in  getting  intelligent,  reliable 
persons  who  will  do  the  work,  and  who  will  dispose  of  the  clean- 
ings properly.  There  is  grave  danger  of  spreading  disease  germs 
if  the  cleanings  are  spilled  on  the  ground  or  along  the  street. 
It  is  necessary  that  the  work  shall  be  regulated  by  ordinances 
and  orders  of  the  board  of  health. 

Final  Disposal. — The  method  of  the  final  disposal  of  privy 
contents  and  of  cesspool  cleanings  is  of  great  importance.  One 
method  is  to  bury  them.  Disease  germs  usually  die  soon  when 
they  are  buried,  for  the  conditions  under  the  soil  are  unfavor- 
able for  their  survival.  House-flies  that  were  breeding  in  the 
buried  matter  when  it  was  buried  may  burrow  to  the  surface 
through  a  foot  of  soil.  The  eggs  of  hookworms  and  tapeworms 
may  survive  for  months  in  the  soil.  Still,  the  burial  of  the  con- 
tents is  a  reasonably  safe  method  of  disposal  if  they  are  covered 
out  of  the  reach  of  chickens  and  dogs.  Burial  is  the  most  prac- 
tical method  of  final  disposal  that  a  rural  health  officer  can  usu- 
ally advise. 

Cesspool  cleanings  and  privy  contents  are  often  used  as  fer- 
tilizers. This  method  of  disposal  may  be  dangerous  if  they  are 
used  for  growing  vegetables  which  are  to  be  eaten  raw,  or  crops 
such  as  potatoes,  which  require  workmen  to  handle  the  soil  with 
their  bare  hands.     It  may  be  safe  when  they  are  used  on  such 


432  THE   HEALTH   OFFICER 

crops  as  wheat  and  hay,  in  which  the  part  that  is  harvested 
does  not  come  in  contact  with  the  soil.  If  the  privy  contents 
are  used  as  fertiHzer,  they  must  be  plowed  under  or  buried 
promptly  in  order  to  remove  the  danger  of  disease  germs  as 
soon  as  possible. 

The  treatment  of  privy  contents  with  chemicals,  such  as 
chlorid  of  lime,  in  order  to  kill  the  disease  germs,  is  too  costly  and 
uncertain  for  practical  use. 

Boiling  human  excretions  in  order  to  kill  the  disease  germs 
in  them  is  about  the  only  sure  method  of  rendering  them  harmless. 
This  method  was  used  in  the  camps  of  laborers  who  built  the 
Catskill  Aqueduct  for  New  York  City's  water-supply.  It  was 
found  to  be  the  cheapest,  the  least  troublesome,  and  the  surest 
method  of  disposing  of  human  excretions  on  a  large  scale.  In 
these  camps  the  excretions  were  poured  into  boilers  and  evapo- 
rated to  dryness,  and  the  residue  was  burned. 

Licensing  Scavengers. — A  method  of  controlling  the  dis- 
posal of  household  wastes  in  villages  is  by  the  licensing  of  scaven- 
gers by  the  municipality.  The  license  is  given  for  permission  to 
cart  the  wastes  over  public  streets.  It  is  necessary  that  the 
municipality  should  provide  a  place  for  the  disposal  of  the 
wastes,  and  to  appoint  inspectors  to  see  that  the  work  is  properly 
done.  The  cost  of  the  disposal  place  and  of  the  inspectors  may 
be  met  by  charging  a  small  fee  for  each  load  that  is  carried  away. 
The  good  behavior  of  the  scavengers  may  be  insured  by  requir- 
ing each  one  to  give  a  small  bond  for  the  proper  performance  of 
his  work. 

If  the  licensing  of  scavengers  is  adopted,  the  board  of  health 
will  be  likely  to  require  that  all  householders  shall  dispose  of 
their  wastes  in  a  sanitary  manner.  The  scavengers  themselves 
will  be  benefited  by  the  increased  work  which  the  system  brings, 
and  by  the  monopoly  which  the  licenses  give  to  them.  They 
can  afford  to  buy  the  proper  equipment  and  to  serve  each  house- 
holder cheaply  and  efficiently. 

Sanitary  Code. — A  great  difficulty  that  a  health  officer  meets 
in  controlling  the  disposal  of  household  wastes  is  that  the  lack  of 
definite  standards  requires  that  he  must  assume  to  set  his  own 
standards,  and  if  the  offender  defies  him,  he  must  prove  that 
his  standards  are  right.  But  if  the  standard  requirements  are 
specified  in  a  sanitary  code,  the  health  officer  can  simply  refer  to 
the  code  for  his  specific  authority.  For  example,  suppose  a 
privy  is  not  fly-tight,  and  a  health  officer  has  the  offender  ar- 
rested. If  there  is  no  provision  in  the  code  requiring  it  to  be 
fly-proof,  the  health  officer  must  prove  that  a  particular  one  is 
dangerous  to  health,  and  he  might  have  great  difficulty  in  doing 


THE    DISPOSAL    OF    HOUSEHOLD    WASTES  433 

SO.     But  if  the  code  requires  it  to  be  fly-proof,  all  that  he  has  to 
prove  is  that  flies  might  easily  enter  its  receptacle. 

The  requirements  of  the  code  relating  to  the  disposal  of  house- 
hold wastes  may  vary  in  difi"erent  districts  according  to  the 
nature  of  the  soil  and  the  social  and  educational  condition  of  the 
people.  It  is  the  duty  of  the  health  officer  to  advise  his  board 
of  health  regarding  the  specific  regulations  that  are  needed  in 
his  district,  and  of  the  board  of  health  to  adopt  them. 

Education. — There  is  great  need  of  educating  the  people  of 
country  districts  in  the  proper  methods  of  the  disposal  of  house- 
hold wastes,  and  of  arousing  a  public  demand  that  the  methods 
shall  be  adopted  throughout  the  community.  A  health  officer 
is  naturally  the  leader  in  this  educational  work.  He  can  dis- 
tribute copies  of  the  sanitary  code  throughout  his  district,  and 
can  explain  the  requirements  when  he  makes  inspections.  He 
can  enlist  the  influence  of  civic  leagues,  village  improvement 
societies,  and  other  public  organizations.  He  can  start  a  few 
prosecutions  with  the  intention  of  impressing  the  public  as 
well  as  of  punishing  the  offenders.  He  can  induce  physicians  to 
approve  his  work  and  to  recommend  it  to  their  patients.  He  can 
influence  school  trustees  and  boards  of  education  to  build  and 
maintain  a  model  privy  at  each  school  house. 

There  is  a  possibility  that  a  health  officer  may  become  too 
enthusiastic,  and  may  attempt  to  enforce  measures  for  which 
public  sentiment  is  unprepared.  The  disposal  of  household 
wastes  is  often  a  matter  of  decency  rather  than  of  public  health, 
and  a  health  officer  must  distinguish  between  the  two  conditions. 
The  complaints  of  one  neighbor  against  another  are  often  the 
results  of  petty  quarrels,  and  are  not  prompted  by  any  desire 
to  promote  health  conditions.  A  health  officer  can  be  misled 
in  the  disposal  of  household  wastes  more  readily  than  in  almost 
any  other  matter.  In  dealing  with  these  conditions  he  has  need 
of  a  double  portion  of  good  sense,  sound  judgment,  and  self- 
control. 
28 


CHAPTER  XrXXVIII 

SEWAGE   DISPOSAL 

Composition  of  Sewage. — When  a  house  is  supplied  with 
running  water,  the  orclinary  method  of  disposing  of  most  house- 
hold wastes  is  to  transport  them  by  flowing  water  to  a  disposal 
plant.  The  mixture  of  household  wastes  and  water  is  called 
sewage.  The  amount  of  sewage  that  is  produced  in  a  house  is 
nearly  equal  to  the  quantity  of  water  that  is  used  in  the  house. 

Sewage  consists  of  the  waste  water  from  kitchens,  laundries, 
and  bath-rooms,  and  of  human  excretions  mixed  with  a  large 
quantity  of  water.  Each  1000  parts  of  sewage  contains  only 
about  1  or  2  parts  of  solid  matter,  of  which  about  one-half  is 
suspended  in  the  water  and  one-half  is  dissolved.  Somewhat 
more  than  one-half  of  the  solids  of  sewage  is  decomposable  organic 
matter,  and  the  remainder  consists  of  substances  (such  as  min- 
erals) which  will  not  decompose.  There  is  not  much  difference 
in  the  average  composition  of  samples  of  sewage  from  various 
sources,  whether  they  are  taken  from  a  large  public  sewer  or 
from  the  discharge  pipe  of  a  small  house. 

Sewage  contains  1,000,000  or  2,000,000  bacteria  in  each  cubic 
centimeter.  About  10  per  cent,  of  the  bacteria  are  colon  bacilli 
from  the  human  intestine.  Some  may  be  disease  germs  that  were 
discharged  from  the  bodies  of  human  beings.  Most  of  the  bac- 
teria are  the  ordinary  ones  of  decay  and  putrefaction. 

Dangers  from  Sewage. — Sewage  is  dangerous  to  health  prin- 
cipally on  account  of  the  disease  germs  which  it  contains.  The 
principal  danger  is  that  the  sewage  may  convey  the  disease  germs 
into  a  well  or  stream  or  ether  source  of  water-supply.  The 
danger  is  not  proportional  to  the  number  of  germs  that  enter 
the  water.  A  few  in  a  glass  of  drinking-water  are  almost  as 
dangerous  as  large  numbers.  The  great  volume  of  water  with 
which  human  excretions  are  mixed  in  sewage  makes  it  probable 
that  disease  germs  will  be  carried  into  a  water-supply  from  an 
elaborate  sewer  system  more  readily  than  they  will  from  the 
undiluted  excretions  of  a  primitive  disposal  place.  The  con- 
veniences of  plumbing  and  of  a  sewage  system  are  accompanied 
by  an  increased  responsibility  for  care  in  the  final  disposal  of  the 
sewage. 

Sewage  flowing  into  a  body  of  water  is  a  menace  to  the  health 
of  those  who  bathe  in  the  water.     There  is  a  possibility  that 

434 


SEWAGE   DISPOSAL 


435 


oysters  taken  from  sewage-laden  water  may  contain  disease 
germs.  The  pollution  of  salt  waters  at  seaside  resorts  may  affect 
the  health  of  visitors  from  inland  towns,  and  of  people  of  com- 
munities in  which  oysters  are  received  from  polluted  waters. 
The  sewage  disposal  system  of  a  community  may  have  an  influ- 
ence on  the  health  of  people  living  far  away  from  the  community. 

Another  danger  from  sewage  is  that  house-flies  may  transmit 
disease  germs  from  it  to  food  or  to  the  mouths  and  eyes  of  per- 
sons. 

An  argument  for  the  proper  disposal  of  sewage  is  that  it  is 
offensive  to  sight  and  smell,  and  is  a  nuisance  that  is  not  to  be 


Fig.  41. — Sewage  in  the  interior  of  a  village  block  that  needs  a  public  sewer  system. 


tolerated  in  respectable  communities.  Cesspools  overflowing 
on  the  ground  are  among  the  principal  nuisances  with  which  a 
rural  health  officer  has  to  deal. 

Disposal  Systems.^ — The  problem  in  sewage  disposal  is  to 
remove  the  decomposable  organic  substances  and  the  bacteria 
from  the  water,  and  to  destroy  them  so  that  they  will  not  be 
offensive  to  the  senses  or  dangerous  to  health.  An  unsuccessful 
disposal  method  that  has  been  thoroughly  tested  is  that  of  hold- 
ing the  sewage  in  a  tank  and  treating  it  with  chemicals,  such  as 
copperas  or  alum,  which  will  coagulate  the  solids  so  that  they  will 
either  float  on  the  surface  or  settle  to  the  bottom.  The  clarified 
liquid  may  then  be  drawn  off.     This  system  is  expensive,  uncer- 


436 


THE   HEALTH    OFFICER 


tain,  and  impractical,  and  a  health  officer  will  seldom  need  to 
give  it  consideration. 

Another  system  is  the  distribution  of  the  sewage  over  the 
surface  of  fami  lands.  This,  too,  has  been  thoroughly  tried, 
and  has  nearly  always  proved  unsuccessful.  The  sewage  has 
very  little  fertilizing  value;  a  large  area  is  required  for  its  disposal; 
the  cost  of  labor  makes  the  system  expensive;  and  the  presence 
of  disease  germs  renders  the  crops  dangerous  for  human  food.  A 
health  officer  will  do  right  if  he  condemns  a  system  of  surface 
disposal  because  of  danger  to  health  and  of  expense. 

A  third  system  of  sewage  disposal  is  to  discharge  the  sewage 
into  a  lake,  or  river,  or  bay,  or  other  body  of  water.     This  is  a 


Fig.  42. — Surface  disposal  of  sewage — a  crude  system. 

dangerous  method  of  disposal,  especially  if  the  body  of  water  is 
used  as  a  source  of  water-supply.  The  natural  purification  of 
the  water  depends  largely  on  the  oxidizing  action  of  the  oxygen 
that  is  naturally  dissolved  in  the  water.  If  the  proportion  of 
sewage  to  the  water  into  which  it  is  discharged  is  as  1  to  200,  the 
quantity  of  oxygen  in  the  water  will  be  decreased  to  such  a  degree 
that  some  kinds  of  fish  cannot  live  in  the  water.  If  the  pro- 
portion of  sewage  to  water  is  as  1  to  50,  the  quantity  of  oxygen 
will  be  decreased  to  such  a  degree  that  putrefaction  may  take 
place.  But  disease  germs  may  remain  alive  in  the  water  even 
though  the  water  does  not  become  offensive  to  the  senses.  One 
of  the  great  problems  with  which  departments  of  health  have  to 
deal  is  the  prevention  of  pollution  of  bodies  of  water  with  sewage. 


SEWAGE   DISPOSAL 


437 


Nearly  every  system  of  sewage  disposal  with  which  a  health 
officer  has  to  deal  depends  for  its  action  on  bacterial  decompo- 
sition, with  a  further  purification  by  oxidation  or  by  filtration 
through  the  soil.  If  the  purification  is  complete,  the  organic 
substances  in  the  sewage  will  either  be  removed  or  completely 
oxidized  to  carbon  dioxid,  water,  and  nitrates,  sulphates,  phos- 
phates, and  other  minerals  which  are  naturally  found  in  ground 
water;  and  the  water  which  flows  away  will  be  free  from  bacteria. 
It  is  possible  to  purify  sewage  to  such  a  degree  that  it  is  fit  for 
use  as  drinking-water. 

The  devices  which  are  commonly  used  for  purifying  sewage 
are:   1,  a  collecting  tank;  2,  subsurface  irrigation  pipes;  3,  a  con- 


Fig.  43. — Two  settling  tanks — one  empty  and  one  filled. 

tact  bed;  4,  a  sprinkling  filter;  5,  a  sand  filter;  and  6,  a  chlorinat- 
ing apparatus.  These  devices  are  often  used  in  various  com- 
binations, as,  for  example,  a  collecting  tank,  a  sprinkling  filter, 
and  a  chlorinating  apparatus. 

Settling  Tank. — Every  efficient  system  of  sewage  disposal 
makes  use  of  a  collecting  tank  in  which  the  raw  sewage  is  re- 
ceived. A  collecting  tank  is  not  filled  and  then  emptied  before 
it  receives  more  sewage,  but  the  sewage  flows  through  it  continu- 
ously. It  is  made  of  sufficient  size  to  hold  at  least  the  quantity 
of  sewage  that  is  produced  during  twelve  or  twenty-four  hours. 
The  sewage  therefore  remains  in  the  tank  for  from  twelve  to 
twenty-four  hours,  and  during  that  time  it  undergoes  two  proc- 


438  THE   HEALTH    OFFICER 

esses:  1,  sedimentation,  and  2.  putrefaction.  While  sewage  is 
flowing  slowly  through  a  collecting  tank,  the  heavy  particles  of 
solid  matter  sink  to  the  bottom,  and  the  lighter  ones  float  on  the 
surface.  For  this  reason  a  collecting  tank  is  often  called  a 
set  III  11^  tank  or  scdimcnlation  basin.  An  efficient  tank  will  usu- 
ally remove  somewhat  less  than  one-half  of  the  solid  matters  that 
are  suspended  in  the  sewage. 

An  active  bacterial  action  also  takes  place  in  a  collecting 
tank.  The  action  is  one  of  putrefaction,  and  for  this  reason  the 
receptacle  is  often  called  a  septic  tank.  The  result  of  the  putre- 
faction is  to  liquefy  some  of  the  solid  bits  of  matter  that  float  in 
the  sewage,  and  to  decompose  some  of  the  substances  that  are 
dissolved  in  it.  The  action  is  rapid  during  the  first  few  hours 
that  a  particular  mass  of  sewage  remains  in  the  tank,  but  after 
that  period  of  time  the  action  is  slow.  There  is  no  advantage  in 
retaining  the  liquid  part  of  sewage  in  a  septic  tank  for  a  longer 
time  than  a  day.  A  septic  tank  will  remove  about  half  of  the 
decomposable  substances  which  are  contained  in  sewage,  and  the 
eftluent  will  undergo  further  offensive  decomposition  unless  it  is 
subjected  to  a  greater  degree  of  purification. 

Cesspool. — The  cesspool  is  the  t}-pe  of  sewage  disposal  plant 
in  which  a  health  officer  is  especially  interested,  for  it  usually 
constitutes  the  entire  disposal  system  of  houses  which  are  not 
connected  with  a  public  sewer  system.  A  cesspool  is  an  under- 
ground septic  tank  from  which  the  liquid  slowly  escapes  through 
the  soil.  The  actions  which  take  place  in  it  are  sedimentation 
and  putrefaction.  The  liquid  which  escapes  is  slowly  filtered 
through  the  soil,  and  its  organic  matter  is  slowly  oxidized  by  the 
oxygen  which  penetrates  the  soil.  The  eflluent  finally  reaches 
the  underground  water.  The  degree  to  which  it  is  purified  will 
depend  largely  on  its  quantity,  the  character  of  the  soil,  and  the 
depth  at  which  the  ground  water  is  reached.  Fine  sand  makes 
an  efflcient  filter.  Coarse  gravel,  or  a  fissure  in  rock,  allows  the 
liquid  to  pass  through  almost  unchanged.  If  the  quantity  is 
considerable,  the  purifying  capacity  of  the  soil  may  be  exceeded. 
If  the  ground  water  lies  near  the  surface  of  the  soil,  the  purifying 
action  will  be  slow,  and  the  eflluent:  will  not  soak  away  from  the 
cesspool. 

Safety  of  a  Cesspool. — The  safety  and  efficiency  of  a  cesspool 
will  depend  principally  on:  1,  the  capacity  of  the  soil  to  absorb 
the  effluent;  2,  its  nearness  to  a  well  or  spring  or  other  source 
of  water-supply;  and,  3,  the  care  with  which  it  is  maintained. 
If  houses  are  near  together,  the  soil  may  be  saturated  with 
sewage  to  such  a  degree  that  all  the  ground  water  is  polluted. 
Under  these  conditions  cesspools  may  still  be  safe  if  all  the  wells 


SEWAGE    DISPOSAL  439 

are  closed  and  only  a  public  water-supply  is  used.  If  the  soil 
has  not  sufficient  capacity  to  absorb  the  effluent,  the  installation 
of  subsurface  irrigation  pipes  will  often  solve  the  problem  of 
the  final  disposal  of  the  liquids  (p.  440). 

Construction  of  a  Cesspool. — A  cesspool  is  usually  constructed 
with  circular  sides  and  arched  top,  and  is  built  of  brick  or  stone 
laid  without  mortar.  No  bottom  is  laid  in  it,  and  perforations 
are  sometimes  left  in  its  sides  to  allow  the  liquid  to  soak  away 
readily.  A  standard  size  for  a  cesspool  of  an  ordinary  house  is  7 
feet  in  diameter  and  the  same  in  depth. 

It  is  necessary  to  provide  a  cesspool  with  a  cover  which  fits 
tightly  enough  to  exclude  flies  and  mosquitoes.  Uncovered 
cesspools  breed  a  large  proportion  of  the  mosquitoes  which  annoy 
the  people  of  villages.  It  is  not  necessary  that  the  cover  should 
be  perforated  for  the  escape  of  gases. 

It  is  economic  to  construct  two  connected  cesspools.  The 
outlet  pipe  of  the  first  cesspool  is  provided  with  an  elbow  which 
extends  downward  about  2  feet  in  order  to  draw  off  only  the  por- 
tion of  the  liquid  which  is  comparatively  clear.  The  bottom  of 
the  first  cesspool  soon  becomes  clogged  with  sediment,  but  the 
bottom  of  the  second  cesspool  should  remain  porous  for  years. 
The  expense  of  frequently  cleaning  a  single  cesspool  will  soon 
exceed  the  cost  of  a  second  one. 

Maintenance  of  a  Cesspool. — A  cesspool  that  is  acting  properly 
will  act  continuously  for  months  and  years.  About  a  foot  of 
sediment  will  collect  on  the  bottom,  and  a  foot  of  scum  wiU  float 
on  the  surface.  This  quantity  of  sediment  and  scum  will  not 
increase,  for  the  processes  of  putrefaction  will  go  on  continu- 
ously, and  win  slowly  reduce  the  solid  matters  to  gases  and 
liquids.  The  perfect  action  of  a  cesspool  requires  that  the  bac- 
terial action  shall  be  as  active  as  possible.  Some  persons  put 
chlorid  of  lime  or  other  antiseptics  into  their  cesspools,  expecting 
to  lessen  the  offensiveness  of  the  sewage.  About  the  only  effect 
of  the  antiseptic  is  the  undesirable  one  of  restraining  the  lique- 
fying action  of  the  bacteria,  thus  increasing  the  quantity  of  sedi- 
ment and  clogging  the  cesspool  until  it  overflows.  Antiseptics 
in  a  cesspool  do  more  harm  than  good. 

When  the  bottom  of  a  cesspool  becomes  clogged,  the  proper 
remedy  is  to  pump  out  the  liquid  contents  and  remove  a  few 
inches  of  the  earth  until  clean  soil  is  reached,  and  replace  it  with 
clean  sand.  If  the  bottom  soil  is  simply  turned  over,  the  mud 
which  clogs  the  soil  remains,  and  the  condition  of  the  cesspool  is 
soon  as  bad  as  ever. 

Large  quantities  of  gases,  such  as  marsh  gas,  are  produced 
during  the  process  of  putrefaction.     The  mixture  of  these  gases 


440  THE  HEALTH   OFFICER 

with  air  is  explosive,  and  serious  accidents  have  resulted  from 
lowering  a  lantern  into  the  cesspools  too  soon  after  they  were 
opened. 

The  final  disposal  of  cesspool  cleanings  is  considered  on  page 
431. 

Subsurface  Irrigation. — When  the  capacity  of  the  soil  to  dis- 
pose of  liquids  is  limited  from  any  cause,  such  as  the  nearness 
of  the  ground  \Vater  to  the  surface  or  the  close  texture  of  the 
subsoil,  a  system  of  subsurface  irrigation  is  often  used  as  an  ac- 
cessory to  a  cesspool.  It  is  also  well  adapted  as  the  main  fea- 
ture of  the  disposal  plant  of  a  large  country  house  or  a  small  in- 
stitution. The  system  consists  of  small  pipes  of  agricultural 
tiling  laid  with  open  joints  in  rows  3  to  6  feet  apart  a  foot  or  two 
beneath  the  surface  of  the  soil.  The  pipes  receive  the  effluent 
from  a  cesspool  or  septic  tank,  and  distribute  it  into  the  upper 
layers  of  the  soil  where  the  oxidizing  and  nitrifying  bacteria  are 
especially  abundant  and  active.  The  pipes  may  be  laid  in  a  front 
yard  with  benefit  to  the  lawn.  An  acre  of  subsurface  irrigation 
tiling  will  take  care  of  from  15,000  to  25,000  gallons  of  sewage 
effluent  daily.  The  heat  of  the  sewage  will  prevent  the  soil 
around  the  pipes  from  freezing  even  when  the  ground  elsewhere 
is  frozen. 

Construction  of  a  Subsurface  Irrigation  Bed. — The  tiling  of 
a  subsurface  irrigation  bed  is  laid  with  a  slope  of  about  4  inches  in 
100  feet  in  order  that  the  in-flowing  sewage  will  not  rush  to  the 
outer  end  of  the  system,  but  will  distribute  itself  uniformly 
through  all  the  tiling.  The  joints  are  wrapped  with  a  thin 
layer  of  excelsior,  and  their  upper  surfaces  are  covered  with 
tarred  paper  in  order  to  exclude  sand  and  yet  allow  space  for  the 
escape  of  the  liquid. 

The  raw  sewage  from  a  house  is  received  into  a  dosing  tank 
whose  capacity  is  equal  to  that  of  the  subsurface  pipes.  An  auto- 
matic device  discharges  the  contents  of  the  filled  tank  suddenly  in 
order  that  the  whole  pipe  system  may  be  flooded.  While  the 
tank  is  refilling,  the  liquid  in  the  pipes  soaks  away,  oxygen  pene- 
trates the  ground,  and  the  soil  becomes  prepared  for  a  new  dose 
of  sewage.  The  service  of  a  sanitary  engineer  is  usually  re- 
quired in  constructing  a  subsurface  irrigation  system. 

W^hen  irrigation  tiling  is  laid  in  order  to  increase  the  capacity 
of  a  cesspool  located  in  a  low  area,  it  is  usually  impossible  to 
construct  a  dosing  tank.  The  effluent  then  drains  into  the  tiling 
constantly,  and  there  is  a  probability  that  a  sediment  will  collect 
in  the  joints  and  finally  clog  them.  One  remedy  for  this  condi- 
tion is  to  build  the  cesspool  above  ground,  sufiiciently  elevated  to 
allow  the  construction  of  a  dosing  tank. 


SEWAGE    DISPOSAL 


441 


Elements  in  a  Disposal  Plant. — It  is  not  economic  to  dispose 
of  large  quantities  of  sewage  effluent  by  direct  absorption  into 
the  soil.  The  plan  that  is  usually  adopted  by  a  large  institution, 
or  a  village,  or  a  city  is  to  subject  the  effluent  to  purification  to  a 
degree  that  it  may  be  safely  discharged  into  a  stream  or  other 
body  of  water.  Four  processes  of  purification  that  are  com- 
monly employed  are:  1,  sedimentation  in  a  septic,  or  settling, 
tank;  2,  oxidation  by  aerobic  bacteria;  3,  filtration;  and  4,  chlori- 
nation.  A  septic  or  settling  tank  is  nearly  always  used  in  every 
system  for  the  preliminary  treatment  of  the  sewage. 


Fig.  44. — The  sprinkling  pipes  and  underdraining  tiling  of  the  stone  bed  of  a  sew- 
age disposal  plant  ready  to  be  covered  with  stone. 


Imhoff  Tank. — When  a  large  quantity  of  sewage  is  treated 
in  a  septic  tank,  there  is  a  considerable  accumulation  of  sedi- 
ment called  sludge.  An  Imhoff  tank  is  a  special  form  of  receiv- 
ing basin  that  is  designed  to  liquefy  the  maximum  amount  of 
sludge,  and  to  require  the  removal  of  the  sludge  with  the  least 
frequency.  It  consists  of  a  deep  concrete  tank  which  is  divided 
into  an  upper  and  a  lower  compartment.  The  bottom  of  the 
upper  compartment  opens  into  the  lower  by  a  narrow  slit.  The 
raw  sewage  is  received  into  the  upper  compartment,  and  as  it 
slowly  flows  along,  its  sediment  falls  into  the  lower  compartment 
and  there  undergoes  putrefactive  decomposition.  The  action 
which  takes  place  in  the  upper  compartment  is  principally  a  sedi- 


442 


IHE    HEALTH    OFFICER 


mentation  of  the  coarser  solids  with  but  Httle  action  by  the  an- 
aerobic bacteria  on  the  liner  soHds  or  the  dissolved  substances. 
The  greater  part  of  the  purilication  of  the  liquid  is  accomplished 
later  by  aerobic  bacteria  to  whose  action  the  effluent  is  subjected 
cither  in  a  contact  bed,  or  a  sprinkling  filter,  or  a  sand  filter. 

Contact  Bed. — A  contact  bed  consists  of  a  large  tank  about  3 
feet  deep  Tilled  with  pieces  of  stone  about  the  size  of  hen's  eggs. 
The  ctiluent  from  the  sedimentation  tanks  is  oxidized  by  aerobic 
bacteria  which  cling  to  the  stones.  After  three  or  four  hours  the 
liquid  is  drawn  ofT  and  the  bed  is  allowed  to  lie  empty  for  a  few 
hours  in  order  that  a  new  supply  of  oxygen  may  penetrate  the 
beds. 


Fig.  45. — A  sand  filter  bed  ridged  and  lurruwt-d  lor  winlur. 


A  contact  bed  will  remove  about  two-thirds  of  the  organic 
matter  and  bacteria  that  is  in  the  liquid.  One  acre  of  beds  will 
treat  about  500,000  gallons  of  sewage  daily  or  about  the  quan- 
tity that  is  produced  by  5000  people. 

Sprinkling  Filter. — A  broken-stone  bed  in  which  the  sewage 
is  sprinkled  upon  the  surface  is  called  a  sprinkling  filter.  Oxida- 
tion in  it  takes  place  rapidly  owing  to  the  intimate  contact  of 
the  liquid  with  the  air,  and  to  the  thin  sheets  in  which  it  trickles 
down  between  the  stones.  An  efficient  sprinkling  filter  will  act 
about  three  times  as  rapidly  as  a  contact  bed,  and  will  remove 
over  80  per  cent,  of  the  solids  and  bacteria  from  the  sewage. 


SEWAGE    DISPOSAL 


443 


Sand  Filter. — A  sand  filter  consists  of  a  bed  of  sand,  usually 
about  one-quarter  of  an  acre  in  area  and  4  feet  deep,  surrounded 


Fig.  46. — Sprinkling  sewage  over  the  stone  bed  of  a  sewage  disposal  plant. 

by  an  embankment,  and  underdrained.     The  effiuent  from  the 
collecting  tank  undergoes  oxidation  and  filtration  in  it,  and  if  the 


Fig.  47. — Sand  filter  of  a  sewage  disposal  plant. 

bed  is  working  properly  over  90  per  cent,  of  the  solids  and  bac- 
teria are  removed.     The  efiiuent  is  discharged  upon  a  sand  filter 


I 


444 


THE   HEALTH    OFFICER 


,  _  _  M 

;Uibulin?  troughs  on  the  sand  filter  of  a  small  sewage  disposal 
plant. 


-W-.  ■•••.*■  A.' 


Fig.  49. — Dried  sediment  on  the  surface  of  a  sand  filter  of  a  sewage  disposal  plant. 

in  a  sudden  gush  only  once  or  twice  a  day.  The  liquid  soaks  away 
quickly,  and  the  nitrifying  bacteria  then  act  on  the  filtrate  for 
some  hours.     If  the  bed  is  continuously  soaked  with  sewage  it 


SEWAGE    DISPOSAL 


445 


will  have  little  or  no  purifying  action,  owing  to  the  impossibility 
of  oxygen  penetrating  it.     A  sand  filter  is  usually  constructed  in 


T'iiifc** 


Fig.  50. — Stone  bed  of  a  sewage  disposal  plant. 


several  beds,  and  the  effluent  is  discharged  upon  each  in  rotation. 
An  acre  of  sand  filter  will  dispose  of  about  100,000  gallons  of  sew- 


Fig.  51. — View  of  an  attractive  sewage  disposal  plant.    The  three  low  houses  in 
the  foreground  cover  the  objectionable  structures. 


age  daily,  or  about  the  quantity  that  is  produced  by  1000  per- 
sons.    A  sand  filter  is  economic  in  sandy  soils  where  land  is  cheap. 


446  THE   HEALTH   OFFICER 

After  a  sand  filter  has  been  in  use  for  some  weeks,  a  scum  of 
grease  and  fine  solids  forms  on  the  surface  and  clogs  the  sand. 
It  is  necessary  that  each  bed  should  be  thrown  out  of  use  fre- 
quently and  dried  in  order  that  the  scum  antl  an  inch  or  two  of 
the  surface  sand  may  be  removed. 

Late  in  the  fall  the  surface  sand  of  a  filter  must  be  deeply 
furrowed  and  ridged  in  order  to  prevent  freezing.  A  layer  of  ice 
forms  on  the  surface  and  is  supported  by  the  ridges.  The  ice 
protects  the  sewage  and  soil  beneath  it  from  freezing.  A  sand 
filter  that  is  properly  ridged  will  remain  in  good  condition 
throughout  a  severe  winter. 

Chlorination. — The  final  process  in  the  complete  purification 
of  sewage  is  the  sterilization  of  the  cflluent  with  chlorin  in  the 
form  of  chlorid  of  lime  or  of  liquid  chlorin.  The  chlorin  acts  by 
combining  with  the  hydrogen  of  the  impurities,  thus  forming  hy- 
drochloric acid  and  liberating  oxygen  in  an  active  form.  The 
oxygen  immediately  combines  with  the  organic  matter  and  bac- 
teria and  oxidizes  them.  The  quantity  of  chlorin  that  is  needed 
will  depend  on  the  amount  of  impurities  that  are  in  the  liquid. 
From  1  to  10  parts  of  chlorin  in  each  1,000,000  parts  of  sewage 
are  usually  required. 

Tests  of  Efficiency. — A  health  officer  can  perform  two  tests 
to  determine  the  efficiency  of  a  sewage  disposal  plant.  The 
first  test  is  the  determination  of  the  stability  of  the  effluent,  or 
its  liability  to  undergo  further  decomposition  and  putrefaction. 
If  the  coarse  particles  are  removed  from  sewage  and  the  total 
amount  of  organic  matter  is  reduced  to  a  quarter  of  its  original 
amount,  the  effiuent  will  usually  be  stable.  The  test  may  be 
performed  by  taking  a  jar  of  the  purified  sewage  and  setting  it 
aside  for  several  days  in  a  room  of  ordinary  temperature.  If  no 
turbidity  or  offensive  odor  develops,  the  sewage  is  stable,  and 
will  not  undergo  decomposition  when  it  is  discharged  into  a  body 
of  water  or  upon  a  filter-bed. 

The  effiuent  from  a  collecting  tank  or  from  a  contact  bed  is 
seldom  stable.  That  from  a  sprinkling  filter  or  a  sand  filter  is 
usually  stable  if  the  system  is  properly  operated. 

A  second  test  of  the  efficiency  of  a  sewage  disposal  system  is 
the  determination  of  the  number  of  colon  bacilli  in  the  treated 
sewage.  Intestinal  bacteria  are  rather  long  lived  in  sewage,  but 
they  do  not  multiply  in  number.  A  disposal  plant  will  reduce 
the  number  of  colon  bacilli  in  about  the  same  degree  that  it  re- 
duces the  .quantity  of  organic  matter.  The  reduction  nn  the 
number  of  colon  bacilli  per  cubic  centimeter  as  the  sewage  passes 
through  the  disposal  plant  is  therefore  a  reliable  indication  of 
the  efficiency  of  the  purification  process,  and  of  the  destruction 


SEWAGE   DISPOSAL  447 

of  disease  germs  which  may  be  in  the  sewage.  A  health  officer 
can  have  the  test  clone  by  sending  samples  of  the  sewage  to  a 
laboratory  in  sterile  2-ounce  bottles.  A  health  officer  must  take 
a  series  of  samples,  one  from  the  stream  of  sewage  before  it 
enters  the  collecting  tank,  one  from  the  stream  of  eflluent  that 
flows  from  the  tank,  one  from  the  effluent  from  the  contact  bed, 
or  sprinkling  filter,  or  sand  fflter,  and  one  from  the  effluent  after 
final  sterilization.  These  samples  will  show  a  progressive  dim- 
inution in  the  number  of  bacilli,  and  none  will  be  found  in  the 
last  sample  if  the  system  is  100  per  cent,  efficient. 

Choice  of  a  System  of  Disposal. — The  system  of  disposal 
that  is  needed  for  a  particular  locality  will  depend  largely  on 
what  disposition  is  finally  made  of  the  effluent.  If  the  effluent  is 
discharged  into  a  large  body  of  water,  an  Imhoff  tank  with  chlorin 
treatment  of  the  effluent  will  constitute  an  efficient  system.  If 
the  effluent  from  a  disposal  plant  is  discharged  into  a  small 
stream  which  is  used  as  a  source  of  water-supply,  it  may  be 
necessary  that  the  disposal  plant  shall  consist  of  a  collecting  tank, 
a  sprinkHng  filter,  a  sand  filter,  and  a  chlorinating  apparatus. 
The  disposal  plant  must  be  adapted  to  the  particular  locality 
which  it  serves. 

Sewer  System. — A  sewer  system  consists  of  collecting  pipes 
o,r  sewers,  and  a  disposal  plant.  A  health  officer  has  little  to  do 
with  the  sewers  directly,  except  when  they  are  broken  or  ob- 
structed. The  construction  and  maintenance  of  sewers  are  en- 
gineering problems  with  which  an  engineering  department  has 
to  deal. 

A  health  officer  has  very  little  power  over  a  private  sewer 
system,  except  to  require  that  the  disposal  shall  be  done  in  a 
sanitary  manner.  He  cannot  require  a  householder  or  the 
managers  of  an  institution  to  install  any  particular  type  of  sewer 
system.  But  a  health  officer  who  understands  sewer  systems  will 
often  be  asked  to  give  advice  regarding  their  installation  and 
management.  If  a  health  officer  condemns  a  sewer  system  at  a 
private  residence,  or  an  institution,  he  should  be  able  to  advise 
the  owners  or  managers  what  system  to  install  in  its  place,  where 
to  locate  the  disposal  plant,  and  how  to  manage  the  system. 

Manufacturers  and  contractors  often  exploit  patented  sys- 
tems which  are  merely  complicated  adaptations  of  well-known 
principles.  A  householder  can  usually  get  a  practical  plumber  to 
design  a  simple,  inexpensive  system  which  is  adapted  to  the 
soil  of  the  locahty.  It  is  a  good  plan  for  a  health  officer  to  con- 
sult the  plumbers  regarding  the  costs  of  standard  sewer  pipes, 
cesspools,  and  disposal  plants  in  his  locality.  A  health  officer 
can  also  promote  public  health  by  advising  the  plumbers  regard- 


448  THE   HEALTH    OFFICER 

ing  the  standard  methods  of  sewage  disposal  which  are  efficient 
and  economic  in  his  locality. 

Public  Sewer  System, — When  a  city,  village,  or  congested 
district  needs  a  public  sewer  system,  the  health  officer  is  the  per-, 
son  from  whom  the  people  and  officials  naturally  seek  advice. 
The  manner  of  establishing  a  sewer  district  is  prescribed  by 
statute  law  in  some  of  the  states.  For  example,  the  New  York 
State  law  relating  to  sewers  in  towns  is  found  in  the  town  law, 
Art.  11,  Sees.  230-248;  and  the  law  relating  to  village  sewers  is 
found  in  the  village  law.  Art.  11,  Sees.  260-278,  and  in  the  public 
health  law.  Art.  3,  Sec.  21a;  and  the  relation  of  sewage  to  stream 
pollution  and  potable  waters  is  found  in  the  public  health  law, 
Art.  5,  Sees.  73-87.  It  is  the  duty  of  a  health  officer  to  know  the 
laws  relating  to  sewers  and  sewage  in  his  district,  and  to  advise 
the  people  and  officials  concerning  them. 

The  question  sometimes  arises  of  the  advisability  of  the  con- 
struction and  operation  of  a  public  sewer  system  by  a  private 
person  or  corporation  who  would  charge  for  its  use.  It  is  not 
wise  to  make  the  use  of  a  sewer  dependent  on  money  payments. 
If  the  water-supply  of  a  house  is  cut  off,  the  occupants  can  obtain 
a  temporary  supply  from  a  neighbor  without  undue  hardship  or 
danger;  but  if  a  house  is  cut  off  from  sewer  connections,  the 
resulting  pollution  of  the  house  and  soil  may  be  dangerous  to 
health. 

Designing  and  constructing  a  public  sewer  system  are  prob- 
lems of  engineering  and  business  which  are  under  the  jurisdic- 
tion of  the  business  department  of  a  municipal  government.  It 
is  the  duty  of  a  health  officer  to  give  advice  regarding  the  sani- 
tary problems  to  be  solved.  But  the  decision  regarding  the 
solution  of  the  problems  does  not  lie  with  him  or  with  the  board 
of  health,  but  with  the  engineering  and  business  departments. 

Operation  of  a  Disposal  Plant. — The  operation  of  a  disposal 
plant  is  under  the  control  of  the  business  departments  of  a  munic- 
ipal government,  but  it  is  the  duty  of  a  health  officer  to  make 
inspections  and  take  bacteriologic  samples  of  the  sewage  in  order 
to  have  records  of  the  efficiency  of  the  plant.  The  health  officer 
of  a  rural  community  is  the  official  who  is  best  qualified  to  take 
samples  and  to  secure  their  examination. 


CHAPTER  XXXIX 

WATER-SUPPLIES 

Pure  Water. — By  pure  water  a  health  officer  means  whole- 
some water,  or  water  that  is  adapted  for  drinking,  cooking,  and 
laundry  purposes.  Water  that  is  used  for  household  purposes 
is  not  pure  in  the  sense  that  it  consists  of  water  alone.  It  always 
contains  dissolved  substances,  such  as  oxygen,  carbon  dioxid, 
and  traces  of  minerals,  but  these  substances  usually  improve  the 
water  rather  than  harm  it. 

Impurities. — The  ordinary  requirements  for  household  water 
are  that  it  shall  be  free  from  color,  odor,  taste,  sediment,  and 
disease  germs.  A  water  may  be  grossly  contaminated  with 
mud,  decayed  leaves,  or  other  suspended  matters;  or  with  color- 
ing-matters derived  from  swamps ;  or  with  putrefaction  products 
derived  from  decaying  substances  in  stagnant  pools,  giving  the 
water  unpleasant  odors  and  tastes.  Gross  contaminations  are 
plainly  evident,  and  automatically  give  warnings  of  possible 
danger. 

Water  may  contain  undesirable  substances  which  do  not  ren- 
der it  unwholesome,  but  which  make  it  undesirable  for  certain 
household  purposes.  An  excess  of  lime  makes  a  water  "hard" 
and  unsuitable  for  laundry  purposes.  An  excess  of  alkalies  or 
salt  may  render  water  unfit  for  drinking  or  cooking.  An  excess 
of  iron  discolors  clothes  which  are  washed  in  it.  A  health  officer 
receives  complaints  about  these  undesirable  impurities  more  fre- 
quently than  he  does  about  the  more  dangerous  ones. 

The  principal  impurities  which  are  dangerous  to  health  are 
disease  germs  derived  from  human  excretions.  Water  from 
lakes,  rivers,  and  underground  sources  is  naturally  free  from  dis- 
ease germs,  and  its  use  will  not  produce  sickness  unless  it  becomes 
polluted  with  disease  germs  of  human  origin.  The  disease  germs 
usually  enter  the  water  with  unpurified  sewage.  The  sewage  on 
farms  and  in  rural  districts  usually  comes  from  privies  and  cess- 
pools which  are  located  without  reference  to  the  underground 
drainage.  The  whole  soil  of  the  built-up  portions  of  villages  and 
cities  is  usually  saturated  with  sewage,  and  the  underground  water 
is  unfit  for  use.  Rivers  and  lakes  are  often  the  receptacles  for 
the  sewage  of  villages  and  cities  which  have  no  sewage  disposal 
systems.  Water  containing  sewage  and  living  disease  germs 
29  449 


450  THE   HEALTH   OFFICER 

may  be  clear  and  may  taste  pleasant.  A  slight  amount  of  gas 
and  mineral  matter  derived  from  sewage  may  improve  the  spark- 
ling appearance  and  the  taste  of  water,  and  may  give  rise  to  a 
false  impression  that  the  water  is  unusually  wholesome. 

The  principal  diseases  which  are  spread  by  means  of  polluted 
water  are  typhoid  fever,  dysentery,  cholera,  and  other  intestinal 
disorders.  These  diseases  are  unusually  prevalent  in  communities 
in  which  the  water-supply  is  polluted  with  sewage;  and  a  puri- 
fication of  the  water  is  followed  by  a  great  reduction  in  the 
number  of  cases  of  t}phoid  fever  in  the  communities.  The 
number  of  deaths  from  typhoid  fever  per  100,000  inhabitants 
of  a  city  may  be  taken  as  a  rough  indication  of  the  purity  of  the 
water-supply  of  that  city. 

Sources  of  Water-supplies. — One  source  of  water-supply  is 
rain-water  stored  in  underground  cisterns.  A  source  of  its 
pollution  is  dust  washed  from  the  roofs  on  which  the  water  is 
collected,  but  that  dust  is  not  likely  to  contain  disease  germs. 
Another  is  dirt  which  falls  through  the  top  of  the  cistern  when  its 
cover  is  out  of  repair.  This  dirt  may  contain  disease  germs. 
Cistern  water  is  usually  wholesome  if  care  is  taken  to  discard 
the  first  water  which  flows  from  the  collecting  roof  after  each 
rain,  and  if  the  cistern  is  kept  in  repair  and  is  cleaned  at  least 
twice  a  year. 

A  spring  of  water  gushing  from  the  ground  will  usually  be 
pure  if  there  is  no  source  of  pollution  near  it  and  if  surface 
water  is  directed  away  from  it. 

A  well  consists  of  a  hole  or  shaft  sunk  through  the  soil  to  an 
underground  source  of  supply.  The  underground  water  will  be 
polluted  with  disease  germs  when  the  quantity  of  sewage  which 
is  deposited  near  the  well  is  so  large  that  the  process  of  its  fil- 
tration through  the  soil  cannot  remove  its  impurities.  The  old- 
fashioned  type  of  well  consisted  of  a  broad,  open  hole  hned  with 
brick  or  stone  laid  without  mortar.  It  permitted  the  entrance 
of  dirt  and  surface  drainage  through  its  top  and  sides.  The 
modern  type  of  well  consists  of  an  iron  pipe  a  few  inches  in 
diameter  driven  or  sunk  into  the  ground,  and  protected  from  sur- 
face drainage.  Replacing  open  wells  with  wells  consisting  of 
iron  pipe  has  greatly  reduced  the  amount  of  t}-phoid  fever  on 
farms  and  in  rural  districts.  No  type  of  well  is  usually  safe  in 
the  built-up  portions  of  villages  and  cities,  owing  to  the  satura- 
tion of  the  soil  with  sewage. 

Lakes  and  rivers  are  frequently  used  as  sources  of  water- 
supplies,  especially  for  cities  and  large  villages.  They  are  fre- 
quently polluted  with  the  contents  of  sewers  both  public  and 
private  and  with  sewage  from  surface  drainage. 


WATER-SUPPLIES  451 

Detection  of  Pollution. — A  health  officer  is  often  asked  to 
examine  a  water-supply  in  order  to  determine  its  purity.  His 
examination  will  consist  of  two  procedures:  1,  inspecting  the 
water-shed  from  which  the  water  is  taken;  and  2,  sending  samples 
of  the  water  to  a  laboratory  for  examination  by  an  expert. 

Examination  of  a  Water-shed.— The  sources  of  pollution  of 
water-supplies  are  usually  privies,  cesspools,  sewer  outlets,  and 
barnyards.  They  can  readily  be  found  and  their  condition  de- 
termined. An  inspection  of  the  water-shed  and  drainage  will 
also  disclose  the  probable  routes  for  the  transmission  of  the  im- 
purities. A  health  officer  will  note  the  location  of  the  sources  of 
pollution  with  reference  to  the  spring,  or  well,  or  the  intake  pipe 
of  a  pumping  station;  the  slope  of  the  surface  of  the  land;  the 
subsoil,  and  its  filtering  capacity;  and  the  direction  of  the  slopes 
of  the  strata  of  soil,  and  of  the  underground  flow  of  water.  He 
will  also  note  the  presence  of  barnyards  and  of  cultivated  fields, 
and  their  relation  to  the  water.  If  a  health  officer  is  inspecting 
a  private  well,  he  will  be  likely  to  find  the  source  of  pollution 
within  100  feet  of  it.  The  pollution  of  the  wells  supplying  the 
water  works  of  a  village  will  usually  be  found  within  a  few 
hundred  feet.  If  the  water  is  taken  from  a  pond  or  a  lake,  the 
inspection  will  include  its  whole  circumference.  It  may  be 
necessary  to  inspect  both  banks  of  a  stream  or  river  for  miles 
up  stream. 

The  effect  of  pumping  must  be  considered  in  judging  the 
probability  of  the  pollution  of  a  well.  Underground  water 
flows  in  a  downhill  direction  along  the  strata  of  soil  in  which  it 
is  contained.  The  natural  rate  of  flow  is  only  a  few  feet  a  day. 
For  example,  it  may  be  from  3  to  30  feet  in  fine  sand.  If  a  cess- 
pool is  located  in  an  uphill  direction  from  a  well ,  the  underground 
flow  of  water  will  be  from  it  toward  the  well;  but  if  it  is  located 
in  a  downhill  direction,  the  underground  flow  will  be  away  from 
the  well. 

Pumping  a  large  quantity  of  water  from  a  well  makes  a 
cone-shaped  depression  in  the  level  of  the  water  immediately 
around  the  well,  and  the  water  then  flows  toward  the  well  from 
every  direction.  The  area  and  depth  of  the  depression  will 
depend  on  the  quantity  of  water  that  is  withdrawn  and  on  the 
rapidity  of  the  pumping.  Suppose,  for  example,  10,000  gal- 
lons of  water  are  pumped  from  a  well  in  an  hour.  This  amount 
of  water  would  fill  an  inverted  cone  3  feet  deep  ha\dng  a  radius 
of  20  feet,  but  since  the  water  is  contained  only  in  the  interstices 
between  the  particles  of  soil,  the  area  aft'ected  will  extend  more 
than  20  feet  in  every  direction  around  the  well.  Water  will 
then  flow  toward  the  well  from  every  direction,  and  the  drain- 


452  THE   HEALTH   OFFICER 

age  from  a  cesspool  located  within  any  part  of  the  affected  area 
might  be  drawn  into  the  well. 

A  health  officer  must  bear  in  mind  the  frequent  practice  of 
using  abandoned  wells  as  cesspools.  Since  they  extend  down 
to  the  ground  water,  no  purifying  action  of  iiltration  takes  place 
in  the  effluent  from  them. 

The  fluorescin  test  is  often  valuable  to  determine  the  flow  of 
sewage  from  a  cesspool  or  sewer  into  a  water-supply.  Fluo- 
rescin is  a  coal-tar  dye  which  in  extremely  diluted  solutions 
imparts  a  greenish  fluorescence  to  water.  If  an  ounce  or  two 
of  the  dye  is  emptied  into  a  cesspool  or  water-closet,  the  ap- 
pearance of  the  characteristic  fluorescence  in  a  well  or  stream 
or  other  source  of  water-supply  that  is  located  near  by  is  proof 
that  sewage  from  that  particular  source  has  entered  the  water. 
A  health  officer  can  readily  make  use  of  this  test  to  determine  the 
flow  of  sewage  from  a  cesspool  to  a  well,  or  to  locate  the  outlet  of 
a  suspected  sewer-pipe. 

Laboratory  Examination  of  Water. — The  laboratory  tests  of 
water  for  household  purposes  are  chemical  and  bacteriologic. 
The  impurities  are  usually  present  in  extremely  small  amounts, 
and  their  detection  requires  the  services  of  skilled  investigators 
and  the  use  of  a  well-equipped  laboratory.  An  analysis  that  is 
not  accurate  is  useless.  Samples  are  frequently  brought  to  a 
health  officer  with  the  expectation  that  he  will  examine  them 
himself.  The  examinations  which  the  ordinary  health  officer 
can  make  are  useless. 

Chemical  Analysis. — When  a  sample  of  water  is  examined, 
its  color,  turbidity,  and  odor  are  first  noted.  A  chemical  anal- 
ysis is  then  made  to  determine  the  quantities  of  the  following 
substances  in  the  water:  total  solids,  minerals,  ammonia,  ni- 
trites, nitrates,  and  chlorin.  The  hardness  of  the  water  and  its 
iron  content  are  often  determined  also.  The  amounts  of  the 
various  substances  in  water  are  usually  expressed  as  parts  per 
million  parts  of  water,  and  sometimes  as  grains  per  gallon. 

Color. — Pure  water  is  naturally  colorless,  but  when  a  con- 
siderable depth  is  viewed  against  a  white  surface,  as  in  a  white- 
tiled  swimming  pool,  it  appears  greenish  blue.  The  water 
which  has  been  stored  in  a  cistern  or  swampy  area  sometimes 
has  a  brown  color  from  the  presence  of  vegetable  dyes  which 
are  dissolved  from  leaves  and  wood.  The  color  has  no  signifi- 
cance so  far  as  the  effect  of  the  water  on  health  is  concerned. 
The  color  is  determined  by  viewing  the  water  contained  in  a 
deep  glass  tube  of  a  standard  size. 

Turbidity  is  the  loss  of  transparence  due  to  solid  particles 
suspended   in   the  water.     These   particles   are   usually   either 


WATER-SUPPLIES  453 

clay,  shreds  of  vegetable  substances,  or  iron.  They  are  usually 
harmless,  but  they  are  to  be  considered  suspicious  until  their 
exact  nature  is  determined. 

Odor. — Whatever  odor  there  may  be  in  water  is  derived  from 
the  animal  or  vegetable  substances  which  are  dissolved  in  the 
water.  Some  of  the  odors  are  characteristic  of  certain  kinds  of 
pollution,  as,  for  example,  the  odor  of  human  perspiration  in 
water  polluted  with  laundry  waste.  The  odor  is  first  determined 
at  room  temperature  by  shaking  a  considerable  quantity  of  water 
in  a  corked  bottle  and  smelling  it  at  the  instant  the  bottle  is 
uncorked.  A  sample  is  then  heated  nearly  to  boihng  in  a  cov- 
ered vessel  and  its  odor  is  noted  at  the  instant  that  it  is  un- 
covered. 

Reservoir  water  often  acquires  unpleasant  odors  and  tastes 
which  are  caused  by  harmless  oils  produced  by  algae  and  diatoms 
growing  in  the  water,  or  by  the  decay  of  the  organisms. 

Solids. — The  total  quantity  of  solid  matter  that  is  dissolved 
or  suspended  in  water  is  determined  by  evaporating  100  c.c.  of 
the  water  to  dryness  and  weighing  the  residue,  which  consists 
of  both  organic  matter  and  minerals.  The  residue  is  then  heated 
to  redness  in  order  to  burn  the  organic  matter.  That  which 
finally  remains  is  mineral  matter,  and  when  its  weight  is  sub- 
tracted from  that  of  the  original  residue,  the  remainder  indicates 
approximately  the  weight  of  the  organic  matter  in  the  water. 

Water  derived  from  sewage  contains  a  considerable  amount 
of  organic  matter.  When  any  water  passes  through  the  soil,  it 
comes  in  contact  with  decomposing  organic  substances  and  car- 
ries some  of  them  along  in  solution.  The  quantity  of  organic 
matter,  or  of  the  characteristic  products  of  the  decomposition  of 
organic  matter,  is  an  indication  of  the  original  degree  of  pollu- 
tion of  the  water,  and  also  of  the  degree  of  its  purification. 
The  organic  matter  consists  of  carbohydrates  and  proteins,  and 
of  bacteria  and  shreds  of  wood  and  leaves,  all  of  which  will  burn. 
The  presence  of  a  large  proportion  of  matter  which  will  burn  is 
an  indication  that  the  natural  processes  of  oxidation  and  puri- 
fication are  incomplete,  and  that  a  considerable  amount  of 
organic  impurities  that  may  possibly  be  harmful  still  remain  in 
the  water.  The  identification  of  the  organic  impurities  is  deter- 
mined principally  by  tests  for  the  nitrogenous  substances,  which 
are  ammonia,  nitrites,  and  nitrates. 

The  greater  part  of  the  substances  which  are  dissolved  in 
water  are  usually  minerals  unless  the  water  is  grossly  polluted. 
The  quantity  of  mineral  matter  in  water  will  vary  widely  from 
the  large  proportion  found  in  mineral  waters  to  the  small  amount 
found  in  water  from  sandy  soil.     A  water  containing  500  parts 


454  THE  HEALTH   OFFICER 

of  total  solids  per  1,000,000  is  not  considered  fit  for  household 
use.  Water  of  good  quality  usually  contains  less  than  100  parts 
of  total  solids  per  l.OOO.OOO. 

Xiiroi^cnoiis  Products. — Ammonia,  nitrites,  and  nitrates  are 
products  of  the  decomposition  of  proteins,  and  contain  the 
nitrogen  of  the  proteins.  Practically  all  the  nitrogen  that  is 
found  in  water  is  deriyed  from  protein  impurities,  especially 
from  sewage  and  decomposing  animal  matter.  The  amount  of 
nitrogenous  substances  in  a  sample  of  water  is  an  indication  of 
the  quantity  of  organic  impurities  which  the  water  contains  or 
has  contained. 

Ammonia. — The  test  for  ammonia  in  water  is  performed  in 
two  stages:  first,  the  detennination  of  the  amount  oi  free  am- 
monia, or  of  ammonia  that  has  already  been  formed;  and  sec- 
ond, the  determination  of  the  albuminoid  ammonia,  or  of  the 
ammonia  which  may  be  formed  out  of  the  undecomposed  pro- 
tein or  albuminous  matter  that  is  in  the  water. 

The  first  stage  of  the  test  for  ammonia  is  performed  by  dis- 
tilling the  ammonia  from  500  c.c.  of  water,  and  adding  the  dis- 
tillate to  tubes  of  Ncssler's  reagent,  which  is  a  standardized  solu- 
tion of  potassium  iodid,  mercuric  chlorid,  and  caustic  soda. 
The  presence  of  ammonia  is  indicated  by  the  appearance  of  a 
yellow  color  in  the  tube.  The  quantity  of  ammonia  is  deter- 
mined by  comparing  the  color  of  the  sample  with  that  of  similar 
tubes  containing  known  quantities  of  ammonia. 

The  second  stage  of  the  ammonia  test  is  performed  by  add- 
ing potassium  pemianganate  and  caustic  soda  to  the  water 
which  remains  after  the  first  distillation,  and  repeating  the 
distillation  and  the  test.  The  protein  in  the  water  is  decomposed 
by  the  permanganate,  and  its  nitrogen  appears  as  ammonia. 

Nitrites. — The  test  for  nitrites  in  a  water  is  a  pink  color  which 
develops  when  a  small  quantity  of  a  standard  solution  of  sul- 
phanilic  acid  and  naphthalymin  is  added  to  a  sample  of  the 
water.  The  quantity  of  nitrites  is  indicated  by  a  comparison 
of  the  color  with  that  of  tubes  in  which  the  test  is  made  with 
known  amounts  of  nitrites. 

Nitrates. — The  test  for  nitrates  in  water  is  made  by  evaporat- 
ing the  water  to  dryness,  treating  the  residue  with  phenol- 
disulphonic  acid  and  an  alkali,  and  diluting  the  mixture  with 
pure  water.  A  yellow  color  indicates  the  presence  of  nitrates, 
and  the  amount  is  indicated  by  a  comparison  of  the  depth  of 
the  color  with  the  colors  of  tested  tubes  containing  known 
quantities  of  nitrates. 

Significance  of  Nitrogenous  ProJwc/^.— Albuminoid  ammonia, 
free  ammonia,  nitrites,  and  nitrates  form  a  series  indicating  sue- 


WATER-SUPPLIES  455 

cessive  degrees  of  the  decomposition  and  oxidation  of  protein 
from  the  unchanged  substance  to  that  which  is  completely 
oxidized.  Ammonia  is  produced  during  the  first  stage  of  de- 
composition, and  is  found  almost  as  soon  as  decomposition 
begins.  As  the  natural  process  of  purification  proceeds,  the 
ammonia  is  acted  upon  by  the  nitrifying  bacteria  of  the  soil 
and  by  other  oxidizing  agents,  and  is  oxidized  first  to  nitrous  acid 
and  then  further  to  nitric  acid,  both  of  which  unite  with  min- 
erals of  the  soil  to  form  nitrites  and  nitrates. 

Albuminoid  ammonia  represents  protein  which  has  not  un- 
dergone decomposition,  and  its  presence  in  any  considerable 
quantity  indicates  that  the  drainage  from  sewage,  manure,  or 
other  decomposing  substance  is  entering  the  water  by  a  fairly 
short  and  direct  route. 

Free  ammonia  is  an  indication  that  a  water  is  receiving  the 
drainage  from  substances  that  have  undergone  some  degree  of 
decomposition  which  is  not  far  advanced.  Some  ammonia 
that  is  derived  from  the  air  may  usually  be  found  in  rain-water, 
but  any  considerable  quantity  in  ground  water  suggests  the 
existence  of  a  nearby  source  of  pollution. 

Nitrites  are  transient  products  that  exist  for  only  a  short 
time  just  before  the  oxidation  of  ammonia  to  nitric  acid  is 
completed.  They  are  not  normally  found  in  water,  and  their 
presence  is  an  indication  that  organic  matter  is  still  undergoing 
decomposition  in  the  water,  but  that  the  process  of  purification 
has  advanced  to  a  greater  degree  than  is  indicated  by  the  pres- 
ence of  ammonia. 

Nitrates  are  stable  mineral  products,  and  form  a  part  of  the 
ashes  which  are  produced  by  the  oxidation  of  protein.  They 
are  found  in  all  soils  and  in  all  ground  waters.  Their  presence 
in  unusual  amounts  is  usually  an  indication  that  a  large  quantity 
of  organic  matter  has  existed  near  the  source  of  the  water,  but 
that  it  has  been  completely  destroyed.  If  an  excess  of  nitrates 
is  found  in  water,  it  would  be  the  duty  of  a  health  officer  to  search 
out  the  source  of  the  decomposing  matter  from  which  they  come, 
and  to  take  steps  to  insure  the  future  purity  of  the  water. 

Chlorin  in  the  form  of  chlorid  of  soda,  or  common  salt, 
is  naturally  found  in  nearly  all  water.  Its  quantity  varies  in 
different  localities,  but  its  natural  amount  in  a  given  locality 
is  fairly  constant.  A  marked  increase  in  its  amount  in  water  is 
an  evidence  of  pollution  with  the  excretions  of  human  beings  or 
of  lower  animals.  Chlorin  may  persist  in  the  water  after  aU 
the  organic  matter  from  which  it  has  been  derived  has  been 
fully  decomposed  and  oxidized. 

The  test  for  chlorin  is  made  by  adding  a  few  drops  of  a  solu- 


456  THE   HEALTH    OFFICER 

tion  of  bichromate  of  potash  to  a  sample  of  the  water,  and  then 
adding  a  standard  solution  of  silver  nitrate  drop  by  drop  until 
the  water  begins  to  appear  red.  The  silver  of  the  silver  nitrate 
unites  with  the  chlorin  of  the  sodium  chlorid  as  long  as  any 
chlorid  is  present,  and  then  it  unites  with  the  potassium  bichro- 
mate, forming  a  red  silver  salt.  The  quantity  of  silver  solution 
that  is  used  before  the  red  color  appears,  compared  with  the 
amount  of  water  tested,  is  an  indication  of  the  proportion  of 
chlorin  in  the  water. 

Bacteriologic  Examination. — Water  nearly  always  contains  a 
few  ordinary  bacteria  of  fermentation  and  decay,  but  these 
kinds  have  httle  significance,  for  they  are  harmless  to  man. 
Thousands  in  each  cubic  centimeter  of  water  would  be  unusual, 
and  would  indicate  the  presence  of  polluting  material  on  which 
the  bacteria  are  living. 

Colon  bacilli  are  the  characteristic  bacteria  of  the  intestines 
of  warm-blooded  animals,  including  man.  They  are  discharged 
in  immense  numbers  with  the  excretions,  and  their  presence  in 
a  water-supply  is  an  indication  of  pollution  with  human  excre- 
tions, sewage,  or  barnyard  drainage,  except  in  the  rare  instances 
of  pollution  with  the  excretions  of  wild  animals  and  birds.  It  is 
almost  impossible  to  detect  and  identify  the  bacteria  of  any 
human  disease  in  water,  but  the  detection  of  colon  bacilli  and 
the  determination  of  their  number  is  easy.  If  colon  bacilli  enter 
a  water-supply,  the  germs  of  typhoid  fever  and  other  intestinal 
diseases  may  enter  it  also.  The  colon  bacilli  are  longer  lived 
and  more  resistant  than  the  germs  of  specific  diseases,  and  their 
absence  from  a  sample  of  water  is  an  almost  sure  indication  that 
typhoid  bacilli  and  all  other  bacteria  derived  from  the  human 
intestine  are  absent  also. 

An  estimation  of  the  number  of  bacteria  in  a  sample  of  water 
is  made  by  mixing  a  small  measured  quantity  of  water  with  a 
gelatin  culture-medium  that  is  liquefied  with  heat,  pouring  the 
mixture  into  a  Petri  dish,  and  counting  the  colonies  that  de- 
velop. Two  series  of  plates  are  usually  prepared,  and  one  is 
incubated  at  the  ordinary  temperature  of  a  room  (20°  C.)  and 
the  other  at  the  temperature  of  the  human  body  (37°  C).  The 
ordinary  bacteria  of  the  soil  do  not  grow  well  at  the  higher  tem- 
perature, while  colon  bacilli  and  disease  germs  do  not  flourish 
at  room  temperature.  The  number  of  bacteria  present  in  each 
cubic  centimeter  of  wholesome  water  will  usually  vary  from  less 
than  a  score  to  over  a  thousand. 

Estimation  of  Colon  Bacilli. — When  colon  bacilli  grow  in 
the  presence  of  certain  sugars,  such  as  lactose  or  dextrose,  they 
produce  gases  and  acids.     In  one  test,  a  sample  of  water  is 


WATER-SUPPLIES  457 

mixed  with  a  liquid  culture-medium  containing  lactose  in  a 
tube  which  is  arranged  in  such  a  way  that  it  catches  any  gas 
that  may  be  produced.  The  production  of  gas  indicates  the 
presence  of  colon  bacilli.  Ox  bile  is  sometimes  added  to  the  cul- 
ture-medium in  order  to  restrain  the  growth  of  all  bacteria 
besides  those  of  the  intestinal  group.  The  test  is  usually  made 
in  a  series  with  1,  0.1,  and  0.01  c.c.  of  water.  The  report  which 
is  made  by  the  laboratory  states  the  smallest  amount  of  water 
in  which  the  colon  bacilli  were  found,  and  from  this  an  estima- 
tion of  the  number  of  bacilli  per  cubic  centimeter  can  be  made. 
If,  for  example,  they  were  found  in  0.1  c.c.  and  not  in  0.01  c.c, 
each  cubic  centimeter  of  the  water  contains  10  bacilli. 

Another  method  of  determining  colon  bacilli  is  to  implant 
the  water  in  a  Petri  dish  containing  a  culture-medium  to  which 
alkaline  or  blue  litmus  is  added  as  an  indicator.  If  colon  bacilli 
are  present,  their  colonies  may  be  recognized  by  their  red  color 
which  develops  as  the  result  of  the  action  of  the  acid  of  the 
bacteria.  The  number  of  red  colonies  indicates  the  number  of 
colon  bacilK  that  were  in  the  sample  of  water  that  was  implanted, 
and  from  this  the  number  in  each  cubic  centimeter  may  be  esti- 
mated. 

The  presence  of  colon  bacilli  in  a  water-supply  usually  in- 
dicates that  the  water  is  polluted  with  sewage  or  the  excretions 
of  human  beings  or  domestic  animals,  and  that  the  source  of 
the  pollution  is  near  by  and  is  likely  to  make  the  water  dan- 
gerous for  household  purposes. 

Collection  of  Sample  s.^While  a  health  officer  is  not  ex- 
pected to  make  a  laboratory  examination  of  water,  he  is  ex- 
pected to  be  able  to  take  samples  for  the  laboratory,  and  to  have 
sufficient  knowledge  to  understand  the  meaning  of  the  labora- 
tory report.  At  least  a  gallon  of  water  is  needed  for  a  chemical 
analysis,  and  the  container  must  be  a  glass-stoppered  bottle  in 
order  to  avoid  contamination  of  the  water.  Laboratories  and 
state  departments  of  health  will  usually  supply  the  containers 
for  both  chemical  and  bacteriologic  examinations. 

In  taking  a  sample,  be  sure  to  obtain  one  that  is  repre- 
sentative of  the  true  condition  of  the  water.  Take  a  sample 
from  a  river  or  lake  at  some  distance  from  the  shore  in  order  to 
avoid  stirring  up  a  sediment.  Be  careful  not  to  touch  the  lower 
part  of  the  stopper  or  the  inside  of  the  neck  of  the  bottle.  If  a 
sample  is  taken  from  a  water-pipe,  allow  the  water  to  run  for  at 
least  five  minutes  before  filling  the  bottle. 

Samples  for  the  bacteriologic  examination  of  water  are 
usually  taken  in  sterile,  2-ounce,  glass-stoppered  bottles.  The 
utmost  care  must  be  taken  to  get  a  representative  sample  and 


458  THE   HEALTH    OFFICER 

to  avoid  the  contamination  of  the  stopper.  It  is  well  to  take 
both  chemical  and  bacteriologic  samples  at  each  collecting  sta- 
tion. Ship  the  samples  by  express  by  the  quickest  route  in 
order  that  they  may  be  examined  before  changes  can  occur  in 
the  water.  If  the  weather  is  warm,  pack  the  bacteriologic 
samples  in  ice. 

Always  send  with  the  samples  a  detailed  description  of  the 
location  at  which  the  samples  were  taken  and  of  the  source  of 
the  water-supply,  whether  from  a  lake,  or  river,  or  well.  If 
from  a  well,  describe  its  depth,  and  the  character  of  the  subsoil, 
and  the  existence  of  cesspools,  barnyards,  privies,  and  other 
possible  sources  of  pollution  near  it.  If  from  a  lake  or  stream, 
describe  the  character  of  the  land  in  its  vicinity,  the  density  of 
population,  the  drainage,  and  the  possible  sources  of  pollution. 

Interpretation  of  Results. — A  health  otiiccr  must  consider 
his  inspection  of  the  water-shed  or  of  the  surroundings  of  a  well 
in  forming  an  opinion  of  the  wholesomeness  of  a  water-supply. 
If  the  report  which  he  receives  indicates  a  possible  pollution,  it 
is  his  duty  to  find  the  source  of  the  suspicious  substances.  If 
he  has  sent  with  the  sample  a  full  description  of  the  drainage 
area  around  the  source  of  the  water-supply,  the  report  of  the 
analyst  will  probably  contain  a  discussion  of  the  sources  of  pollu- 
tion and  suggestions  for  the  proper  remedies.  It  often  happens 
that  a  suspicious  substance  has  no  significance,  as,  for  example, 
a  considerable  amount  of  chlorin  in  water  near  the  seashore. 

Typical  Analyses. — The  following  tables  are  the  results  of 
the  analyses  of  two  samples  of  water  taken  on  the  same  day. 
One  sample  was  from  the  public  water  drawn  from  wells  located 
on  the  outskirts  of  a  village.  The  other  was  from  a  driven  pump 
located  near  the  congested  center  of  the  village.  The  subsoil 
is  sandy  and  the  ground-water  level  is  10  feet  below  the  surface. 
The  figures  indicate  parts  per  1,000,000: 

Public  Water-supply.  Private  Water-supply. 

Color,  trace.  Trace. 

Odor,  faint  vegetable.  Faint  vegetable. 

Turbidity,  slight.  Pronounced. 

Solids,  total,  69.  197. 

Loss  on  ignition,  9.  40. 

Mineral  residue,  60.  157. 

Iron,  1.80.  4.88. 

Ammonia,  free,  0.016.  0.156. 

Ammonia,  albuminoid,  0.014.  0.022. 

Nitrites,  0.001.  0.010. 

Nitrates,  0.060.  24.000. 

Chlorin,  5.00.  25.75. 

Hardness,  14.00.  67.40. 

Bacteria  per  cubic  centimeter,  25.  5. 

Colon  bacilli  in  30  c.c.  of  water,  0.  0. 


.WATER-SUPPLIES  459 

The  water  from  the  public  works  is  pure  and  wholesome. 
The  color  and  turbidity  are  caused  by  iron  rust.  The  rather 
high  percentage  of  chlorin  is  caused  by  the  location  of  the  vil- 
lage on  the  seashore. 

The  color  and  turbidity  of  the  private  water-supply  are  due 
to  iron  rust  which  had  accumulated  in  the  storage  tank.  The 
high  chlorin  content  indicates  that  a  great  quantity  of  sewage 
and  stable  drainage  had  entered  the  ground  water;  and  an  inspec- 
tion of  the  locality  revealed  many  cesspools  and  two  livery 
stables  within  a  block  of  the  well.  The  large  amount  of  nitrates 
indicates  pollution,  but  also  that  oxidation  and  destruction  of 
most  of  the  sewage  had  taken  place.  The  increased  quantity 
of  ammonia  and  nitrites  indicates  that  some  of  the  sewage  is 
incompletely  destroyed.  The  increase  in  hardness  is  probably 
due  to  the  minerals  contained  in  the  sewage.  The  absence  of 
colon  bacilli  indicates  that  the  pollution  has  not  yet  reached  a 
degree  in  which  intestinal  bacteria  may  survive  and  produce 
sickness.  The  analysis  shows  that  the  water  is  polluted,  and  a 
consideration  of  the  surroundings  indicate  that  the  well  must 
soon  be  abandoned. 

Periodic  Examinations. — When  there  is  reason  to  suspect  a 
constantly  increasing  danger  of  pollution  of  a  well,  periodic  anal- 
yses of  the  water  will  reveal  the  progression  of  the  pollution. 
There  will  first  be  an  increase  of  the  nitrates  and  chlorin,  next, 
of  the  nitrites,  and  then  of  the  ammonia.  Later,  colon  bacilli 
will  occasionally  appear,  and  finally  will  be  present  constantly. 
Periodic  examinations  are  necessary,  for  example,  when  new 
houses  are  constantly  being  built  near  water  works  which  are 
located  on  the  outskirts  of  a  village,  for  there  will  come  a  time 
when  the  increase  of  population  will  cause  a  dangerous  degree 
of  pollution  of  the  water. 

Prevention  of  Water  Pollution. — One  of  the  duties  of  a  health 
ofhcer  is  to  give  advice  regarding  the  prevention  of  pollution  of 
water,  and  how  to  secure  a  wholesome  supply.  If  the  water- 
supply  for  a  farm  or  an  isolated  dwelling  is  a  well,  the  preventive 
measures  are  to  place  the  well  in  a  location  where  the  effluent 
from  cesspools,  privies,  and  barnyards  cannot  reach  it;  to  con- 
struct the  well  water-tight  from  the  surface  to  a  depth  of  at 
least  3  feet ;  and  to  locate  all  places  for  sewage  disposal  at  a  safe 
distance  and  direction  from  the  well.  If  a  spring  is  used,  the 
preventive  measure  is  to  remove  all  sources  of  pollution  from  its 
vicinity.  If  a  cistern  is  used,  the  preventive  measures  are  to 
clean  it  frequently,  to  keep  it  covered  closely,  and  to  see  that 
the  first  water  that  runs  from  the  collecting  roof  after  a  shower 
is  discarded. 


460  THE  HEALTH   OFFICER 

Household  Purification. — Small  filters  are  sometimes  sold  to 
purify  water  for  household  use.  Nearly  all  of  them  are  worse 
than  useless,  for  they  become  dirty,  and  bacteria  grow  in  them 
luxuriantly.  The  only  ones  that  have  any  value  are  those  of  the 
Chamberlain  or  Berkefeld  t}pe  which  are  made  of  porous 
earthenware  similar  to  those  used  in  bacteriologic  laboratories. 
But  even  these  require  daily  cleansing,  and  the  slowTiess  with 
which  the  water  passes  through  them  renders  their  use  im- 
practical. 

Purijkation  by  Boiling. — The  surest  method  which  a  health 
officer  can  recommend  for  purifying  water  at  home  is  that  of 
boiling  it,  for  the  heat  will  kill  all  bacteria  of  disease  that  may  be 
in  it.  Boiling  the  water  for  some  minutes  e.xpels  the  oxygen 
which  is  dissolved  in  it,  and  the  water  then  has  a  flat,  unpleas- 
ant taste.  This  taste  may  be  prevented  by  removing  the  water 
from  the  heat  just  as  it  begins  to  boil,  or  by  shaking  the  boiled 
water  in  a  jar  in  order  to  restore  the  oxygen  to  it.  If  a  health 
officer  is  suspicious  of  the  quality  of  a  water,  it  is  his  duty  to 
insist  that  it  be  boiled  before  it  is.  used  for  drinking,  or  for  the 
preparation  of  food,  or  for  washing  dishes. 

It  is  frequently  the  practice  in  rural  districts  to  go  to  some 
trouble  to  secure  safe  water  for  cooking  and  drinking,  and  to 
use  a  polluted  supply  for  the  laundry  and  for  scrubbing.  This 
is  by  no  means  a  safe  or  desirable  practice,  and  it  is  the  duty  of 
the  health  officer  to  use  every  possible  means  to  secure  a  pure 
supply  for  e\'er}'  purpose. 

Purification  of  Public  Water-supplies.  ^ — One  of  the  most 
important  duties  of  a  health  officer  is  to  keep  himself  informed 
regarding  the  analysis  of  the  public  water-supplies  of  his  dis- 
trict, and  the  possible  sources  of  pollution  of  the  w^ater-shed 
from  which  the  supplies  are  drawn.  The  duty  and  powers  of 
remedying  unsafe,  threatening  conditions  lies  with  the  board 
of  health  and  the  executive  officers  of  the  business  department 
of  a  municipality;  but  the  health  officer's  duty  is  to  keep  the 
officers  and  the  public  informed  regarding  the  conditions,  to 
advocate  the  proper  remedies,  and  to  call  the  state  department 
of  health  to  his  assistance  if  necessary. 

A  great  difficulty  in  securing  action  for  preserving  the  pur- 
ity of  a  water-supply  is  that  judges  and  juries  usually  require 
legal  proof  that  sickness  has  actually  resulted  from  the  use  of 
that  particular  water,  or  that  particular  kinds  of  disease  germs 
have  actually  entered  the  water.  There  is  a  great  need  of  laws 
which  shall  fix  the  responsibility  for  remedying  unsafe  conditions 
of  a  water-supply,  and  which  shall  prescribe  definite  measures 
and  legal  proceedings  to  secure  the  remedy  promptly. 


WATER-SUPPLIES  461 

Chlorination. — If  a  public  water-supply  is  polluted,  an  effi- 
cient method  of  its  purification  is  to  add  chlorin  to  it.  The 
apparatus  needed  is  the  same  that  is  used  in  chlorinating  sew- 
age (page  446).  The  object  of  the  chlorination  is  to  kill  the 
bacteria,  especially  the  disease  germs,  in  the  water.  The  quan- 
tity of  chlorid  of  lime  or  of  liquid  chlorin  required  is  usually  1 
or  2  parts  per  1,000,000,  and  is  so  small  that  it  can  scarcely  be 
detected  by  taste  or  a  chemical  analysis  of  the  treated  water. 
An  appraatus  for  applying  liquid  chlorin  can  be  installed  in  a 
few  hours,  and  there  is  no  excuse  for  delaying  its  use  when  pollu- 
tion becomes  known.  The  Department  of  Health  of  New  York 
State  has  a  portable  outfit  for  applying  liquid  chlorin  which  it 
sends  out  for  use  in  emergencies. 

Efifect  of  Reservoirs. — Two  measures  which  are  used  for 
purifying  water  on  a  large  scale  are  storage  in  a  reservoir  and 
filtration. 

When  water  is  stored  in  a  reservoir,  its  solid  particles,  includ- 
ing bacteria,  settle  to  the  bottom,  and  the  bacteria  are  killed 
by  the  action  of  the  sunhght.  It  is  necessary  that  the  water 
shall  pass  through  the  reservoir  slowly  and  that  the  sediment 
shall  not  be  disturbed. 

The  reservoir  must  have  a  capacity  equal  at  least  to  a  day's 
consumption  of  water,  for  at  least  a  day  is  required  to  produce 
a  great  reduction  in  the  number  of  bacteria.  Storage  in  a  reser- 
voir does  not  produce  complete  purification,  but  it  is  of  great 
value  preliminary  to  further  treatment. 

Filtration  through  sand  is  the  process  that  is  usually  adopted 
for  the  purification  of  water  on  a  large  scale.  A  sand  filter 
consists  of  a  bed  of  sand  about  4  feet  in  depth  contained  in  a 
covered  tank  of  concrete,  and  underdrained  to  carry  off  the 
purified  effluent.  A  filtration  plant  is  usually  built  in  units  of 
small  beds  for  convenience  of  operation  and  cleaning. 

Filter  beds  are  of  two  kinds,  the  slow  type  and  the  rapid. 
The  principal  difference  between  the  two  is  in  the  method  of 
operation. 

Slow  Filtration. — In  the  slow  ty^Q  of  filtration  the  water  is 
allowed  to  flow  over  the  bed  to  a  depth  of  about  1  foot  and  to 
sink  away  at  the  rate  of  about  4  inches  per  hour.  This  gives 
the  bed  a  capacity  of  between  2,000,000  and  3,000,000  gallons  a 
day  per  acre.  The  action  of  the  filter  is  to  remove  solid  particles, 
including  bacteria,  from  the  water.  It  has  no  action  on  sub- 
stances dissolved  in  the  water.  The  purifying  action  of  the 
bed  takes  place  principally  in  the  upper  2  or  3  inches  of  sand, 
and  is  dependent  on  a  gelatinous  growth  of  micro-organisms 
which  forms  on  the  grains  of  sand.     A  filter-bed  is  inefficient 


462  THE   HEALTH    OFFICER 

until  this  growth  has  formed.  It  is  the  gelatinous  matter,  and 
not  the  sand  itself,  which  catches  the  impurities  and  holds  them 
back  from  the  water  which  passes  through  the  tilter. 

A  slow  sand  filter  will  remain  in  action  about  a  month, 
and  then  the  gelatinous  growth  will  obstruct  the  interstices 
between  the  sand  grains  and  pre\'ent  the  passage  of  the  water. 
The  filter  must  then  be  drained  and  an  inch  or  two  of  sand  re- 
moved from  its  surface  in  order  to  restore  its  permeability. 
After  a  few  months  of  ser\'ice  the  bed  becomes  reduced  in  thick- 
ness and  the  sand  must  be  returned. 

Rapid  Filtration. — When  water  is  purified  by  rapid  filtra- 
tion, alum  or  copperas  is  added  to  it  in  order  to  coagulate  some 
of  the  dissolved  substances.  When  the  water  passes  through  the 
filter-bed,  the  flocculent  coagulum  adheres  to  the  sand  grains, 
and  acts  in  the  same  manner  as  the  gelatinous  micro-organisms 
in  a  slow  filter.  A  rapid  sand  filter  will  act  about  ten  times  as 
fast  as  a  slow  filter,  but  the  filter  must  be  cleaned  every  day. 
The  cleansing  is  done  by  forcing  water  backward  through  the 
sand  in  order  to  wash  the  coagulum  from  the  sand  grains. 
Chlorin  is  usually  added  to  a  public  water-supply  after  it  has 
been  filtered. 

The  choice  between  the  slow  and  the  rapid  systems  of  filtra- 
tion is  principally  an  economic  and  engineering  problem.  A 
filter  of  either  t}pe  that  is  properly  operated  will  remove  98  per 
cent,  of  the  bacteria  from  a  water.  Sand  filtration  of  the  public 
water-suppfies  of  cities  which  formerly  had  polluted  water  has 
produced  a  great  reduction  in  the  amount  of  t}phoid  fever  in 
those  cities.  For  example,  Albany  takes  its  water-supply  from 
the  Hudson  River,  which  contains  the  sewage  from  Troy,  ten 
miles  up  stream.  Sand  filtration  was  introduced  in  1899. 
Albany's  annual  death-rate  from  t}'phoid  fever  before  the  water 
was  filtered  was  90  per  100,000  of  population;  after  filtration  it 
dropped  at  once  to  21. 

It  is  a  question  which  is  the  more  efficient  and  economic 
method  for  cities  located  on  rivers  to  adopt,  to  render  their 
sewage  effiuents  completely  pure  and  sterile,  or  to  purify  the 
water-supplies.  It  is  probable  that  both  methods  will  be  re- 
quired in  the  future. 

Hardness  of  Water. — What  is  called  hardness  in  water  is 
caused  principally  by  lime  and  magnesium  dissolved  in  the 
water,  mostly  in  the  form  of  carbonates.  When  soap  is  mixed 
with  hard  water,  it  combines  with  the  lime  and  magnesium  and 
forms  an  insoluble  scum — 1  grain  of  lime  will  neutralize  8  grains 
of  soap.  There  is  a  great  waste  of  soap  when  hard  water  is 
used,  and  the  scum  which  is  formed  is  objectionable.     A  water 


WATER-SUPPLIES  463 

containing  12  parts  of  lime  or  magnesium  per  1,000,000  is  con- 
sidered to  be  hard;  50  parts  per  1,000,000  indicates  excessive 
hardness.  The  hardness  has  no  effect  on  health,  but  a  health 
officer  ought  to  understand  its  principles  in  order  to  advise  those 
who  inquire  about  the  condition. 

A  gallon  of  pure  water  will  dissolve  about  2  grains  of  car- 
bonate of  lime,  but  if  it  contains  carbon  dioxid,  it  will  dissolve 
five  or  ten  times  as  much.  If  hard  water  containing  carbon 
dioxid  is  boiled,  the  gas  will  be  driven  off,  and  a  part  of  the 
mineral  matter  will  be  separated  from  the  water  and  will  be 
precipitated  as  sediment,  and  some  will  be  left  in  solution. 
The  hardness  caused  by  carbon  dioxid  is  called  temporary 
hardness,  while  that  caused  by  lime  dissolved  in  the  water  alone 
is  called  permanent  hardness. 

The  test  for  hardness  is  to  add  a  solution  containing  a  known 
quantity  of  soap  to  the  water  drop  by  drop,  shaking  the  bottle, 
and  noting  when  a  lather  forms.  The  quantity  of  soap  used 
indicates  the  amount  of  lime  and  magnesium  that  is  in  the  water. 

There  is  no  practical  method  of  overcoming  the  permanent 
hardness  in  water,  but  the  temporary  hardness  may  be  overcome 
by  boiling  the  water.  It  may  also  be  overcome  by  adding  freshly 
slaked  lime  which  unites  with  the  carbon  dioxid.  The  removal 
of  the  carbon  dioxid  reduces  the  solvent  power  of  the  water,  and 
the  lime  that  was  held  in  solution  by  the  gas  becomes  insoluble 
and  falls  as  a  precipitate. 

Iron. — ^A  health  officer  is  frequently  consulted  on  account  of 
iron  in  the  water.  Iron  in  laundry  water  stains  the  clothes 
red.  It  gives  an  unpleasant  taste  to  water.  If  often  forms  an 
iridescent  scum  which  looks  like  oil  on  the  surface  of  the  water. 
It  unites  with  the  tannin  of  the  leather  in  the  valves  of  pumps, 
and  forms  black  ink,  which  may  give  the  impression  that  some 
one  has  poisoned  the  water.  When  water  contains  an  excess 
of  iron,  a  micro-organism,  called  crenothrix,  may  grow  in  the 
water-pipes  and  form  a  gelatinous  mass  which  may  fill  the  pipes. 
Particles  of  the  growth  may  break  off  and  make  the  water  tur- 
bid, or  decay  and  give  the  water  an  unpleasant  odor  and  taste. 
Driven  pumps  that  are  used  in  kitchens  are  often  affected  with 
the  crenothrix.  The  effects  of  iron  in  household  water  simulate 
all  manner  of  unsanitary  conditions  of  the  water,  and  yet  the 
iron  has  no  perceptible  effects  on  health.  A  health  ofl&cer  is 
often  perplexed  in  explaining  the  unpleasant  conditions  produced 
by  iron  in  water,  and  in  making  sure  that  iron  is  actually  the 
cause  of  the  trouble. 

Iron  in  water  is  usually  that  which  has  been  dissolved  from 
the  soil.     It  is  dissolved  in  a  ferrous  state  in  which  it  is  soluble 


464  THE   HEALTH   OFFICER 

in  water,  but  when  it  comes  in  contact  with  air,  it  is  oxidized 
to  a  ferric  state,  in  which  it  is  insoluble  and  falls  as  a  red  pre- 
cipitate of  so-called  iron  rust.  This  is  the  usual  manner  of  the 
fomiation  of  the  red  sediment  in  water  pitchers  in  which  water 
stands  for  a  few  hours,  and  of  the  red  mud  which  often  forms  in 
the  bottoms  of  storage  tanks.  Iron  is  likely  to  give  trouble  if 
more  than  h  part  per  1,000,000  is  present  in  water.  Little  can 
be  done  to  prevent  trouble  with  iron  in  kitchen  pumps.  If  a 
storage  tank  is  used,  the  iron  will  become  oxidized  and  will  be 
precipitated  after  the  water  has  stood  for  some  hours.  If  the 
intake  and  outlet  pipes  are  arranged  in  such  a  way  that  they  do 
not  disturb  the  sediment,  storage  in  a  broad,  shallow  tank  will 
remove  a  large  part  of  the  iron. 

Public  water  works  often  have  trouble  with  iron-rust  in  the 
water.  One  method  of  removing  the  iron  is  to  aerate  the  water 
by  passing  it  over  a  grating,  storing  it  in  a  reservoir,  and  filter- 
ing it  if  necessary.  The  aeration  oxidizes  the  iron  to  an  insoliible 
form  in  which  it  subsides  to  the  bottom  of  the  storage  tank. 


CHAPTER  XL 

VENTILATION 

Definition. — The  subject  of  ventilation  embraces  a  study  of 
the  various  conditions  of  the  air  of  enclosed  spaces  in  their 
effects  upon  human  beings.  The  health  officer  is  especially 
interested  in  the  effects  of  air  that  is  modified  by  housing,  breath- 
ing, and  occupations  upon  persons  who  breathe  such  an  at- 
mosphere. The  principal  conditions  of  the  air  which  may  affect 
health  are  its  chemical  composition,  temperature,  humidity, 
movements,  dust,  and  living  organisms. 

The  air  affects  the  body  chemically  through  the  organs  of 
respiration,  and  physically  by  contact  with  the  skin.  Many 
atmospheric  conditions  with  which  a  health  officer  has  to  deal 
affect  the  skin  much  more  than  the  lungs. 

Composition  of  Outdoor  Air. — The  standard  of  purity  of  the 
air  is  that  of  the  outdoor  air  of  the  fields  and  woods.  Such  air 
is  composed  of  gases  in  about  the  following  proportions: 

Per  cent. 

Oxygen 20.94 

Nitrogen 78.09 

Argon 0.94 

Carbon  dioxid 0.03 

Helium,  ammonia,  nitric  acid,  etc trace 

The  proportions  of  the  various  gases  of  outdoor  air  do  not 
vary  appreciably  in  various  samples,  no  matter  from  what  lo- 
cality the  samples  are  taken,  except  in  those  taken  in  the  im- 
mediate vicinity  of  sources  of  gross  pollution.  The  weight  of 
air  over  every  square  inch  of  the  surface  of  the  earth  is  15  pounds, 
and  that  over  each  square  foot  is  1  ton.  This  amount  is  so 
great  that  whatever  gases  can  be  taken  from  the  outdoor  air  are 
insignificant  in  comparison  with  the  whole  quantity  of  the 
atmosphere;  and  those  which  can  be  poured  into  the  air  are 
soon  diluted  to  harmless  traces.  The  only  situations  in  which 
foreign  gases  are  usually  present  in  outdoor  air  in  appreciable 
amounts  are  the  immediate  vicinity  of  volcanoes,  chemical  fac- 
tories, and  gas  plants.  The  gaseous  composition  of  the  outdoor 
air  of  crowded  streets  of  cities  is  practically  the  same  as  that  of 
rural  districts.  Fresh,  wholesome  air  is  as  available  to  city 
dwellers  as  to  the  people  of  the  country.  The  healthfulness  of 
30  465 


466  THE  HEALTH    OFFICER 

the  air  of  the  seashore,  the  mountains,  the  forests,  and  the 
prairies  depends  on  other  factors  than  its  chemical  composition. 

Temperature. — The  body  regulates  its  temperature  by  vary- 
ing the  elimination  of  its  heat  into  the  surrounding  atmosphere. 
It  is  adjusted  to  li\e  with  comfort  in  air  at  a  temperature  of 
about  68°  F.,  which  is  about  30  degrees  cooler  than  itself;  but 
it  can  adjust  itself  to  air  that  is  100  degrees  or  more  cooler. 
As  the  temperature  of  the  air  rises  above  that  for  the  maximum 
comfort,  the  body  has  increasing  difhculty  in  getting  rid  of  its 
heat.  Feelings  of  uneasiness,  restlessness,  dulness,  sleepiness, 
and  headache  then  develop,  and  there  is  a  feeling  of  oppression 
in  breathing.  Later  the  temperature  of  the  body  rises,  faint- 
ness  comes  on,  and  a  heat-stroke  develops. 

The  effects  of  an  air  temperature  approaching  that  of  the 
body  depend  largely  upon  the  humidity  of  the  air.  The  body 
eliminates  its  heat  by  radiation  into  the  air  and  by  the  evapora- 
tion of  perspiration.  If  the  air  is  dry,  the  evaporation  of  per- 
spiration may  be  sufficiently  rapid  to  cool  the  body  even  when 
the  temperature  of  the  air  is  higher  than  that  of  the  body. 

Humidity. — The  atmosphere  always  contains  vapor  of  water. 
The  quantity  of  water  that  it  can  hold  depends  principally  upon 
its  temperature.  One  cubic  foot  of  air  at  32°  F.  can  hold  2.2 
grains,  while  at  70°  F.  it  can  hold  7.9  grains,  and  at  90°  F.,  14.3 
grains. 

The  humidity  of  the  air  is  usually  expressed  by  the  degree  of 
its  saturation  with  moisture.  If  it  contains  all  the  moisture 
that  it  can  hold,  its  humidity  is  100  per  cent.  If  it  contains  only 
one-quarter  as  much  as  it  can  hold,  its  humidity  is  25  per  cent. 
If  the  humidity  is  less  than  40  per  cent.,  the  air  is  noticeably 
dry.  It  seldom  falls  below  10  per  cent,  even  in  deserts.  The 
humidity  of  outdoor  air  on  foggy  days  is  100  per  cent. 

Humidity  may  be  measured  with  a  hygrometer  consisting  of 
a  pair  of  w^et  and  dry  bulb  thermometers.  The  bulb  of  one  *is 
enclosed  in  a  bag  of  wet  muslin,  and  the  evaporation  of  the 
water  cools  the  mercury.  If  the  temperature  of  the  dry  bulb 
and  the  difference  between  the  readings  of  the  thermometers 
are  noted,  the  humidity  may  be  read  from  tables  which  are 
furnished  with  the  instrument.  For  example:  if  the  tempera- 
ture indicated  by  the  dry  bulb  is  80°  F.,  and  that  by  the  wet 
bulb,  75°  F.,  the  humidity  is  79  per  cent.  If  the  air  is  saturated 
with  moisture,  no  evaporation  will  take  place.  The  tempera- 
tures of  the  two  bulbs  will  be  identical  and  the  humidity  will 
be  100  per  cent. 

Humidity  effects  health  principally  by  its  influence  on  the 
temperature  of  the  body.     A  high  degree  of  humidity  prevents 


VENTILATION  467 

the  evaporation  of  perspiration.  If  both  the  temperature  and 
the  humidity  of  the  air  are  high,  the  heat-regulating  mechanism 
of  the  body  may  be  unequal  to  its  task.  The  bofly  temperature 
will  then  rise  and  there  will  be  a  fever  and  sickness;  but  if  the 
humidity  is  low,  the  evaporation  from  the  skin  may  be  sufficient 
to  keep  the  body  cool  even  on  a  hot  day.  A  humidity  of  80  per 
cent,  makes  an  air  temperature  of  75°  F.  feel  uncomfortably 
warm,  but  if  the  humidity  is  50  per  cent.,  an  air  temperature  of 
90°  F.  may  not  be  oppressive. 

The  temperature  which  a  person  feels  on  a  hot  day,  and 
the  danger  that  may  be  apprehended  from  the  heat,  are  indi- 
cated by  the  reading  of  a  wet  bulb  thermometer,  for  the  bulb 
that  is  bathed  in  moisture  is  in  the  same  condition  as  the  skin 
of  a  perspiring  person.  If,  for  example,  an  ordinary  thermom- 
eter shows  a  temperature  of  85°  F.,  while  that  of  a  wet  bulb 
indicates  75°  F.,  one's  sensation  of  warmth  is  that  of  75  degrees 
and  not  of  85  degrees. 

Moisture  increases  the  capacity  of  cold  air  to  conduct  heat 
away  from  the  body.  Humid  air  at  a  temperature  of  32°  F. 
feels  almost  as  cold  as  dry  air  at  zero. 

Neither  a  high  nor  a  low  degree  of  humidity  has  much  effect 
upon  the  body  when  the  temperature  of  the  air  is  between  60° 
and  70°  F.  A  humidity  of  between  60  and  70  per  cent,  is  usually 
considered  to  be  the  most  comfortable  and  healthful. 

Air  Movements. — Air  currents,  like  humidity,  influence 
health  chiefly  through  their  effect  on  body  temperature  by  favor- 
ing the  evaporation  of  perspiration  and  the  conduction  of  heat 
from  the  skin.  The  oppressiveness  of  a  hot,  humid  day  is  greatly 
relieved  by  a  gentle  breeze  even  when  the  temperature  and 
humidity  remain  unchanged. 

Dust  in  Outdoor  Air. — Particles  of  solid  matter  are  always 
suspended  in  the  air.  They  are  derived  principally  from  smoke, 
dust  raised  by  the  wind,  substances  ejected  from  volcanoes,  and 
mineral  matter  from  sea  spray.  The  number  of  particles  in 
each  cubic  centimeter  is  enormous.  Observers  find  hundreds 
in  the  purest  air  of  mountain  tops,  and  hundreds  of  thousands 
in  the  vicinity  of  cities.  The  dust  in  the  air  has  an  important 
effect  on  our  comfort  and  welfare,  for  its  particles  condense 
moisture  on  their  surfaces.  They  take  up  the  excess  of  watery 
vapor  from  the  air  and  give  it  back  slowly,  and  thus  have  a  great 
effect  in  regulating  the  temperature  of  the  air.  They  are  the 
centers  on  which  water  condenses  to  form  clouds.  Each  par- 
ticle of  mist  in  a  fog  and  each  raindrop  has  a  bit  of  dust  for  a 
center.  If  there  were  no  dust  in  the  air,  moisture  would  con- 
dense on  every  object  on  the  surface  of  the  earth,  and  our 


468  THE  HEALTH   OFFICER 

clothing  and  houses  would  be  constantly  wet.  The  natural 
dust  of  the  air  is  beneficial  to  mankind,  and  almost  the  only 
exception  is  that  pollen  grains  inhaled  may  cause  hay-fever  or 
asthma  in  susceptible  persons.  Smoke  has  little  or  no  injurious 
effect  upon  the  body  of  a  person  who  breathes  it,  and  its  sup- 
pression is  desirable  more  for  economic  and  esthetic  reasons  than 
on  public  health  grounds.  Smoke  and  other  solid  particles  in 
outdoor  air  are  soft  and  small,  and  lack  the  size  and  sharpness 
which  constitute  the  principal  danger  in  the  dust  of  occupations. 

Living  Organisms  in  Outdoor  Air. — Bacteria  and  molds  may 
nearly  always  be  obtained  from  the  outdoor  air,  but  their  num- 
bers are  not  large.  About  50  bacteria  may  usually  be  obtained 
from  each  cubic  foot  of  air  in  rural  districts,  and  from  75  to  100 
in  city  streets.  Nearly  all  these  bacteria  belong  to  harmless 
varieties.  Probably  the  most  abundant  disease  germs  are  those 
which  produce  pus  in  wounds,  but  only  about  10  or  20  can  usu- 
ally be  found  in  each  100  cubic  feet  of  air  cither  in  the  country 
or  the  city.  The  number  of  bacteria  in  the  air  is  increased  when 
much  dust  is  raised  by  the  wind,  but  they  are  seldom  or  never 
so  abundant  in  outdoor  air  as  to  afTect  health.  Even  the  air 
of  sewers  is  almost  free  from  bacteria. 

Weather  and  Climate. — Atmospheric  conditions  which  ordi- 
narily affect  our  senses  constitute  the  weather  and  climate. 
The  principal  weather  conditions  which  affect  health  are  those 
of  sunlight,  temperature,  moisture,  and  air  currents.  The  body 
has  a  great  natural  ability  to  adapt  itself  to  these  varying  con- 
ditions, and  the  adaptibility  is  made  almost  complete  by  means 
of  artificial  clothing  and  housing. 

Weather  conditions  in  our  homes  may  be  opposite  to  those 
out  of  doors.  The  indoor  air  of  a  heated  house  on  a  foggy  day 
may  have  a  humidity  of  30  per  cent.,  while  that  out  of  doors  is 
100  per  cent.  The  air  of  a  kitchen  or  sitting-room  often  has  a 
temperature  of  85°  F.  and  a  humidity  of  100  per  cent.,  while 
the  outdoor  air  is  at  zero  temperature.  The  violent  changes 
from  indoor  to  outdoor  weather  to  which  most  persons  subject 
themselves  many  times  daily  in  winter  are  vastly  greater  than  the 
natural  daily  changes  in  the  outdoor  weather.  It  is  unreason- 
able to  ascribe  sickness  to  the  changeable  outdoor  weather  when 
no  harm  comes  from  frequent  exposure  to  greater  contrasts 
between  indoor  and  outdoor  weather  conditions.  Bad  weather 
affects  health  principally  because  it  leads  people  to  stay  indoors 
where  there  are  abundant  chances  of  contact  infection. 

Indoor  Air. — While  human  beings  are  adapted  to  live  health- 
ful lives  amid  the  changes  which  naturally  take  place  in  the 
outdoor  air,  they  are  readily  affected  by  some  of  the  conditions 


VENTILATION  469 

which  develop  in  the  air  of  closed  rooms  as  the  result  of  breath- 
ing and  of  fires.  Air  which  has  been  inhaled  or  made  foul  by 
breathing  and  combustion  produces  bad  effects  upon  the  body 
bqth  immediately  and  also  remotely.  The  immediate  effects 
are  dulness,  oppressive  breathing,  headache,  and  general  dis- 
comfort, and  are  almost  exactly  similar  to  those  produced  by 
warm  air  at  a  temperature  near  that  of  the  body. 

The  remote  effects  of  foul  air  are  a  general  lowering  of  bodily 
vigor,  and  a  vague  weakness  and  lack  of  tone.  These  effects 
may  best  be  appreciated  by  contrasting  them  with  the  tonic 
effects  of  the  fresh  air  in  the  outdoor  treatment  of  tuberculosis. 

The  changes  which  a  health  officer  has  to  consider  in  the 
air  of  dwelhng  houses,  assembly  halls,  and  other  enclosed  meet- 
ing places  are  those  in  its  chemical  composition,  temperature, 
humidity,  and  movements,  and  in  its  content  of  dust  and  living 
organisms. 

Composition  of  Indoor  Air. — The  change  which  takes  place 
in  the  gaseous  composition  of  the  air  of  an  occupied  room  is 
similar  to  that  which  is  produced  in  inspired  air  by  respiration. 
The  following  table  shows  the  approximate  composition  of 
expired  air  contrasted  with  that  of  outdoor  air.  The  two  sides 
of  the  table  do  not  exactly  balance  because  some  of  the  gases 
of  the  inspired  air  are  eliminated  by  the  kidneys  and  skin: 

Outdoor  air,         Expired  air, 
per  cent.  per  cent. 

Oxygen 20.94  16.4 

Nitrogen  and  other  inert  gases 79.03  79.03 

Carbon  dioxid 0.03  4.1 

Organic  gases none  trace 

The  degree  of  the  change  in  indoor  air  depends  on  the  num- 
ber of  persons  breathing  the  air,  the  length  of  their  stay  in  the 
room,  and  the  quantity  of  outdoor  air  that  is  admitted.  Under 
ordinary  conditions  excessively  foul  air  will  still  contain  over 
20  per  cent,  of  oxygen,  and  its  carbon  dioxid  will  not  be  much 
above  0.4  per  cent. 

The  effects  of  respired  air  upon  the  body  have  been  care- 
fully tested  upon  persons  confined  in  a  respiratory  chamber  in 
which  the  air  could  be  analyzed,  the  work  done  by  the  subjects 
measured,  and  every  condition  of  the  experiments  estimated 
with  accuracy.  These  experiments  have  been  repeated,  ampli- 
fied, and  confirmed  since  1913  by  the  New  York  State  Commis- 
sion on  Ventilation.  They  prove  that  a  diminution  in  the 
amount  of  oxygen  and  an  increase  in  the  carbon  dioxid  produce 
no  discomfort  or  other  noticeable  effects,  provided  the  humidity 
and  temperature  of  the  air  remained  normal.     For  example,  a 


470  THE   HEALTH    OFFICER 

group  of  students  were  confined  in  the  experimental  chamber 
until  their  respiration  lowered  the  proportion  of  oxygen  in  the 
air  to  17  per  cent,  and  raised  that  of  carbon  dioxid  to  2  per 
cent.,  while  the  temperature  and  humidity  of  the  air  were  kept 
normal.  These  students  felt  no  discomfort,  and  their  physical 
and  nervous  functions  showed  no  appreciable  change.  Yet 
matches  lighted  by  the  students  would  not  burn,  owing  to  the 
diminution  of  the  oxygen.  The  oxygen  content  of  the  air  which 
the  students  breathed  in  the  experimental  chamber  was  reduced 
to  four-fifths  of  its  normal  amount,  while  that  in  extremely 
badly  ventilated  halls  and  factories  has  very  seldom  been  found 
to  be  reduced  to  ij  of  its  usual  proportion. 

Similar  experiments  prove  that  carbon  dioxid  does  not  begin 
to  be  harmful  to  man  until  it  has  accumulated  to  such  an  ex- 
tent that  it  forms  1  per  cent,  of  the  inspired  air,  or  thirty  times 
its  usual  proportion  in  the  air.  But  it  is  not  found  in  the  air  of 
crowded  and  poorly  ventilated  rooms  in  greater  amounts  than 
ten  or  fifteen  times  its  proportion  in  outdoor  air. 

There  is  a  great  margin  of  safety  in  the  air  of  every  poorly 
ventilated  meeting  place  and  dwelling  house  so  far  as  the  con- 
tent of  carbon  dioxid  and  oxygen  is  concerned.  The  reason  for 
this  fact  is  evident  when  the  physiology  of  respiration  is  con- 
sidered. The  air  that  remains  in  the  alveoli  of  the  lungs  after 
a  forcible  expiration  contains  about  16  per  cent,  of  oxygen  and 
5  per  cent,  of  carbon  dioxid.  An  abundance  of  oxygen  can  enter 
the  lungs  when  it  forms  18  to  20  per  cent,  of  the  air.  Carbon 
dioxid  can  pass  off  from  the  lungs  and  into  external  air  which 
contains  1  or  2  per  cent,  of  the  gas. 

Experiments  have  been  made  by  collecting  the  organic  sub- 
stances which  are  expelled  from  the  body  with  the  ex-pired  air, 
and  injecting  them  into  animals.  The  experiments  at  first 
seemed  to  show  that  they  are  poisonous,  but  when  they  were 
repeated  with  due  care,  nothing  poisonous  has  been  found  in 
them.  The  substances  give  an  unpleasant  odor  to  the  foul  air 
of  a  room,  but  they  produce  no  hamiful  effects  upon  the  body. 

Temperature,  Humidity,  and  Movement. — The  factors  of 
temperature,  humidity,  and  movement  of  the  air  are  closely 
related  in  the  ventilation  of  occupied  rooms.  The  body  heats 
the  inspired  air,  and  its  whole  surface  imparts  heat  to  the  sur- 
rounding atmosphere.  Moisture  is  expelled  with  expired  air  and 
evaporated  from  the  skin.  The  atmosphere  of  a  closed,  un- 
ventilated  room  is  practically  motionless,  and  a  blanket  of  warm, 
humid  air  surrounds  each  person  who  sits  quietly  in  it.  The 
heat,  humidity,  and  calmness  act  upon  the  body  in  the  same 
manner  as  the  same  weather  conditions  on  a  calm,  sultry  day  of 


VENTILATION  471 

midsummer.  Nearly  all  the  effects  of  the  air  of  unventilated 
rooms  will  be  reproduced  upon  a  person  who  breathes  air  that 
is  warm,  humid,  and  motionless,  even  when  the  air  is  chemically 
as  pure  as  that  out  of  doors.  The  effects  are  due  princii)ally 
to  the  interference  with  the  elimination  of  heat  from  the  body, 
and  not  to  the  chemical  effect  of  the  air. 

The  following  experiments  illustrate  the  effects  of  the  various 
factors  that  are  concerned  in  ventilation: 

1.  When  persons  entered  a  respiratory  chamber  in  which  the 
air  chemically  pure  was  kept  at  a  temperature  of  80°  F.  and  the 
humidity  at  80  per  cent.,  depressing  effects  were  felt  within  a 
few  moments,  but  were  relieved  by  starting  an  electric  fan  which 
caused  the  air  to  circulate  and  dissipate  the  heat  from  the  bodies 
of  the  subjects. 

2.  When  the  air  in  a  respiratory  chamber  was  breathed  over 
and  over,  it  became  extremely  impure  according  to  its  oxygen 
and  carbon  dioxid  content;  its  temperature  and  humidity  rose; 
and  the  subjects  felt  its  depressing  effects  keenly.  The  subjects 
then  breathed  fresh  outdoor  air  admitted  to  their  noses  and 
mouths  through  tubes,  but  there  was  no  relief  of  their  feelings. 
Persons  standing  outside  the  chamber  then  breathed  the  hot, 
moist,  impure  air  that  was  drawn  from  the  chamber,  and  they 
felt  no  discomfort  or  ill  effects.  Electric  fans  were  then  started 
in  the  chamber,  and  the  subjects  in  it  were  quickly  reheved,  as 
in  the  previous  experiments. 

Such  experiments  as  these  demonstrate  that  the  chief  effects 
of  air  vitiated  by  respiration  are  physical  and  not  chemical ;  and 
that  the  principal  parts  of  the  body  that  are  directly  affected 
are  the  skin  and  the  heat  regulating  system,  and  not  the  lungs 
and  the  respiratory  system.  A  rise  in  the  body  temperature  of 
from  1°  to  1°  F.  usually  results  from  prolonged  exposure  to  air 
which  has  a  temperature  of  75°  F.  and  a  humidity  of  75  per  cent. 

Dust. — The  number  of  particles  of  inorganic  dust  in  the  air 
of  occupied  rooms  is  usually  many  times  greater  than  the  num- 
ber out  of  doors.  The  number  in  each  cubic  foot  of  air  of  oc- 
cupied school  rooms  is  usually  over  a  million,  and  when  dust  is 
raised  by  violent  movements  of  the  pupils,  the  number  reaches 
several  millions.  The  ordinary  inorganic  dust  of  school  rooms 
and  other  meeting  places  is  seldom  harmful  in  itself,  for  its 
particles  are  soft  and  light,  and  the  mucous  membrane  of  the 
nose  readily  collects  them  and  prevents  them  from  entering  the 
body.  The  dust  which  is  particularly  harmful  is  that  of  occu- 
pations, and  consists  of  sharp,  heavy  particles  of  metals  and 
minerals,  and  of  poisonous  substances,  such  as  lead  or  arsenic. 
Dust  containing  bacteria  from  human  sources  is  also  harmful. 


472  THE   HEALTH   OFFICER 

Bacteria. — The  number  of  bacteria  in  the  air  is  greatly  in- 
creased when  dust  is  raised.  While  the  number  in  the  air  of 
dwellings,  schools,  office  buildings,  and  factories  is  usually  less 
than  500  per  cubic  foot,  it  sometimes  rises  to  5000  or  more  when 
the  floors  and  furniture  are  unclean.  The  air  transmission  of 
diseases  is  now  considered  to  be  very  exceptional,  but  still  a 
real  danger  of  its  occurrence  may  exist.  It  is  proved  that  cases 
of  various  contagious  diseases  may  be  safely  treated  in  one  ward 
when  great  cleanliness  of  both  the  attendants  and  of  the  room 
is  maintained.  But  it  is  reasonable  to  expect  that  living  bac- 
teria will  be  found  in  the  air  of  filthy  rooms  when  diseased  per- 
sons soil  the  floor  with  their  expectoration,  vomited  matter,  and 
excretions.  Every  Health  oflicer  knows  that  these  conditions 
frequently  exist  in  dwellings  and  even  in  meeting  places.  If  the 
infected  matter  is  dried,  and  is  raised  as  dust  by  tramping  feet 
within  a  few  minutes  after  its  expulsion  from  the  body,  the  air 
will  very  likely  contain  living  disease  germs  in  sufficient  numbers 
to  spread  infection.  It  is  a  common  habit  for  men  to  expector- 
ate upon  the  floor  and  to  scrape  their  feet  over  the  ejected  matter 
in  order  to  wipe  'out  the  visible  evidence  of  it.  The  substances 
dry  almost  irnmed lately,  and  are  raised  as  dust  before  the  bac- 
teria have  time  to  die.  The  danger  of  infection  with  dust  will 
be  increased  by  infectious  matter  contained  in  droplets  ex-pelled 
by  the  acts  of  spitting,  coughing,  and  sneezing  (page  170). 
The  dust  of  filthy  dwellings  and  meeting  places  must  be  consid- 
ered to  be  a  menace  to  health. 

Ventilation. — The  object  of  the  ventilation  of  occupied 
rooms  is  to  maintain  the  air  in  a  condition  which  approximates 
that  of  the  outdoor  air  on  a  pleasant,  temperate  day  of 
summer.  The  principal  factors  which  are  to  be  considered  are 
its  cleanliness,  chemical  composition,  temperature,  humidity, 
and  currents. 

Cleanliness  of  indoor  air  is  indicated  by  its  freedom  from  dust 
and  odors.  It  depends  principally  upon  the  source  of  the  sup- 
ply, and  upon  the  cleanliness  of  the  room  and  its  occupants. 
The  air  of  filthy  rooms  will  be  dusty,  will  contain  many  bacteria, 
and  will  have  a  foul  odor. 

Chemical  Composition. — Although  the  carbon  dioxid  pro- 
duced by  respiration  is  seldom  harmful  in  itself,  yet  it  is  usually 
taken  as  an  indicator  of  the  vitiation  of  the  air  and  of  the  effi- 
ciency of  ventilation.  The  standard  of  the  chemical  purity  of 
indoor  air  is  that  its  percentage  of  carbon  dioxid  shall  not  be 
more  than  two  or  three  times  that  of  the  outdoor  air.  The 
following  computation  will  illustrate  the  method  of  estimating 
the  amount  of  fresh  air  that  is  required  in  v'entilation: 


VENTILATION  473 

30  number  of  cubic  inches  of  air  in  each  inspiration. 

0.04     percentage  of  carbon  dioxid  in  expired  air. 
1.2       cubic  inches  carbon  dioxid  exhaled  per  breath. 
18  number  of  inspirations  per  minute. 

21.6       cubic  inches  carbon  dioxid  exhaled  per  minute. 
60  minutes  in  one  hour. 

1296  cubic  inches  =  0.7  cubic  foot  =  amount  of  carbon 

dioxid  exhaled  per  hour. 

0.7  ^  0.0003  (the  percentage  of  carbon  dioxid  in  outdoor  air) 
=  2333  =  number  of  cubic  feet  of  air  in  which  the  percentage  of 
carbon  dioxid  would  be  doubled  in  one  hour  by  the  respirations 
of  one  person.  The  standard  quantity  of  fresh  air  which  is  usually 
adopted  by  ventilating  engineers  is  2000  cubic  feet  per  hour  for 
each  adult  person  occupying  a  closed  room.  Experience  has 
shown  this  to  be  a  safe  standard  for  health,  comfort,  and  de- 
cency. 

The  carbon  dioxid  test  that  is  used  in  the  laboratory  of  the 
New  York  City  Department  of  Health  is  as  follows: 

Collect  a  sample  of  air  by  taking  a  2-gallon  bottle  or  jug 
filled  with  water  into  the  room  from  which  the  air  is  to  be  taken. 
Empty  the  bottle,  cork  it  tightly,  and  carry  it  to  the  laboratory. 
Add  a  known  quantity  of  a  solution  of  barium  hydroxid  (BaOH2) 
with  phenolphthalein  as  an  indicator  of  acidity,  and  shake  it 
well.  The  carbon  dioxid  will  combine  with  the  barium  to  form 
an  insoluble  carbonate,  BaCOs-  Add  oxalic  acid  carefully  until 
the  color  is  just  discharged.  The  oxalic  acid  will  combine  with 
that  part  of  the  barium  which  has  not  combined  with  the  car- 
bon dioxid.  If  the  quantities  of  barium  and  of  oxalic  acid  are 
known,  the  quantity  of  carbon  dioxid  in  the  bottle  may  be  cal- 
culated. 

Odor  Test. — ^Air  that  has  been  made  foul  by  breathing  has 
an  unpleasant  odor  which  comes  from  the  breath  and  perspira- 
tion whether  the  room  and  its  occupants  are  clean  or  not.  The 
intensity  of  the  odor  is  a  fairly  reliable  indicator  of  the  degree 
of  the  foulness  of  the  air.  When  the  percentage  of  carbon  dioxid 
has  risen  to  6  parts  per  10,000',  the  odor  begins  to-be  apparent; 
and  when  it  reaches  10  parts,  the  odor  is  very  pronounced.  A 
health  officer  may  properly  condemn  the  ventilation  of  a  room 
if  he  can  detect  the  odor  of  foul  air  on  entering  it.  The  sense  of 
smell  soon  becomes  dulled,  and  the  odor  is  not  noticeable  after 
the  air  has  been  inhaled  a  few  moments,  and  so  the  test  must  be 
made  on  coming  directly  from  the  fresh  air. 

Temperature. — The  standard  temperature  that  is  usually 
adopted  for  dwellings,  school  rooms,  and  meeting  halls  is  68°  F. 
for  the  great  mass  of  the  air,  with  a  permissible  tempearture  of 


474  THE   HEALTH   OFFICER 

10  degrees  lower  on  the  floor  and  beside  the  windows  and  doors. 
If  the  difference  in  the  temperatures  of  the  various  parts  of  the 
room  is  more  than  10°  F.,  there  will  be  uncomfortable  drafts  of 
cold  air  in  the  room.  A  standard  requirement  is  that  the  aver- 
age temperature  of  incoming  air  shall  not  be  more  than  10°  F. 
lower  than  that  of  the  room  air. 

Each  person  in  a  room  gives  off'  about  100  calories  of  heat 
per  hour.  One  calorie  will  raise  the  temperature  of  20  cubic 
feet  of  air  10°  F.  The  heat  which  each  person  gives  off  in  an 
hour  will  raise  the  temperature  of  2000  cubic  feet  of  air  10°  F.; 
2000  cubic  feet  of  air  per  hour  admitted  at  a  temperature  of 
58°  F.  will,  therefore,  be  raised  to  a  temperature  of  68°  F.  by 
the  heat  that  is  produced  by  one  person.  Under  ordinary 
conditions  of  heating  and  ventilation,  if  the  heating  of  an 
empty  room  is  adjusted  to  maintain  a  constant  temperature 
of  68°  F.,  and  a  number  of  persons  enter  the  room,  a  con- 
stant supply  of  2000  cubic  feet  of  fresh  air  per  person  at  a  tem- 
perature of  58°  F.  will  maintain  the  room  at  a  temperature  of 
68°  F.  continuously.  If  the  standard  requirement  of  fresh  air 
is  calculated  on  a  heat  and  temperature  basis,  it  will  agree  with 
that  calculated  on  the  basis  of  carbon  dioxid. 

Humidity. — The  standard  degree  of  humidity  of  occupied 
rooms  is  60  per  cent,  at  a  temperature  of  68°  F.  The  humidity 
may  be  as  low  as  30  per  cent,  without  apparent  injur}^  to  health, 
but  the  air  will  be  perceptibly  dry,  and  will  have  deleterious 
eft"ects  on  the  furniture  and  other  contents  of  the  room.  If  the 
humidity  is  raised  above  60  per  cent,  by  breathing,  the  tempera- 
ture of  the  air  will  probably  be  raised  also,  and  the  evil  effects 
of  poor  ventilation  will  be  felt. 

Each  person  gives  off  about  2  ounces  of  water  to  the  air  during 
each  hour  with  the  breath  and  perspiration.  Each  cubic  foot 
of  air  at  68°  F.  and  60  per  cent,  humidity  will  contain  about 
5  grains  of  moisture ;  and  2000  cubic  feet,  which  is  the  standard 
requirement  per  person  per  hour,  will  contain  about  20  ounces. 
Each  person  in  a  room  will  give  off  2  ounces  or  10  per  cent, 
additional  moisture,  and  will  raise  the  humidity  of  the  air  sup- 
ply to  70  per  cent.  If  a  room  receives  only  1000  cubic  feet  of 
fresh  air  per  person  per  hour,  the  humidity  will  rise  to  80  per 
cent.,  which  is  too  high  for  comfort  and  health.  The  standard 
requirement  of  2000  cubic  feet  of  fresh  air  per  person  per  hour 
is  usually  adequate  for  maintaining  the  proper  degree  of  humid- 
ity of  a  room. 

The  humidity  of  the  air  of  a  room  on  a  cold  day  may  be 
roughly  estimated  by  observing  the  condensation  of  moisture 
on  the  windows.     If  the  windows  are  dripping  with  moisture, 


VENTILATION  475 

the  air  is  too  humid  for  health  and  comfort.  The  combined 
temperature  and  humidity  of  the  air  may  be  measured  Ijy 
means  of  a  wet  and  dry  bulb  thermometer  (page  466 j. 

Air  currents  are  necessary  in  order  to  change  the  air  of  an 
occupied  room,  and  also  to  remove  the  blanket  of  warm,  moist 
air  that  forms  around  the  body  of  a  person  who  sits  quietly  in 
calm  air.  It  is  often  a  difficult  problem  to  maintain  the  cur- 
rents without  producing  uncomfortable  drafts. 

A  current  velocity  of  3  or  4  feet  per  second  will  deflect  a 
light  curtain,  and  may  be  felt  as  a  movement.  A  slower  velocity 
will  be  felt  as  a  chill  if  the  temperature  of  the  incoming  air  is 
considerably  lower  than  that  of  the  room. 

Air  Space. — The  air  currents  will  depend  largely  upon  the 
size  of  themr  space  of  a  room.  The  air  of  a  room  cannot  ordi- 
narily be  changed  more  than  six  times  per  hour  without  produc- 
ing unpleasant  currents  and  drafts.  If  2000  cubic  feet  of  air 
per  hour  per  person  are  to  be  supphed  by  changing  the  air  of  a 
room  six  times  per  hour,  each  person  will  require  333  cubic 
feet  of  air  space.  A  standard  requirement  per  person  in  meeting 
places  is  500  cubic  feet.  The  New  York  State  requirement  of 
space  for  a  public  school  is  200  cubic  feet  per  pupil  in  the  lower 
grades  and  more  in  the  upper  grades.  This  minimum  amount 
is  considered  to  be  adequate,  for  teachers  are  presumed  to  have 
intelligence  to  observe  the  air  conditions  and  interest  to  operate 
the  ventilating  system. 

Methods  of  Ventilation. — Natural  ventilation  depends  upon 
the  wind,  and  upon  the  difference  between  the  temperature  of 
air  in  a  room  and  that  out  of  doors.  The  wind  may  either  force 
air  into  a  room,  or  it  may  exhaust  the  air  from  it  by  blowing 
across  windows  and  other  openings. 

The  expansion  of  air  by  heat,  and  the  difference  in  weight 
between  warm  and  cold  air,  produce  an  outward  flow  of  warm 
air  from  a  room,  and  of  cold  air  into  it.  A  great  exchange  of 
air  takes  place  through  cracks  in  the  windows,  doors,  and  floors, 
and  through  the  walls  of  houses.  Experiments  show  that  8 
cubic  feet  of  air  per  hour  will  pass  through  each  square  yard  of 
brick  wall  when  the  air  of  an  enclosed  space  is  10°  F.  warmer 
than  that  outside. 

Open  windows  are  the  most  convenient  of  all  means  of 
ventilation.  A  frame  covered  with  thin  mushn  fitted  to  the 
window  like  a  mosquito  bar  will  prevent  unpleasant  air  cur- 
rents. These  frames  are  efhcient  in  the  ventilation  of  cow^  barns, 
and  are  equally  efficient  in  bedrooms. 

Ventilators  in  the  ceihng  allow  the  hot  air  to  rise  out  of  the 


476  THE  HEALTH   OFFICER 

room,  while  cool,  fresh  air  enters  through  windows,  doors,  cracks, 
and  other  openings. 

Hot-air  furnaces  ventilate  as  well  as  heat  a  house,  but  the 
system  is  usually  inadequate  for  school  houses  and  meeting  halls. 

Artificial  Systems. — The  ventilation  of  large  buildings  is 
usually  accomplished  either  by  the  plenum  system,  in  which  air 
is  forced  into  the  rooms;  or  by  the  vacuum  system,  in  which  the 
air  is  exhausted  from  them;  or  by  a  combination  of  the  two 
methods.  The  systems  require  constant  expert  attention.  The 
artificial  control  of  the  air-supply  makes  it  possible  to  remove  the 
dust  and  to  add  moisture  to  the  air.  It  is  even  possible  to  wash 
the  air  that  has  circulated  through  the  rooms  and  to  use  it  over 
again. 

Methods  of  Heating.— The  great  value  of  an  open  fireplace 
is  that  it  is  an  efhcient  ventilator.  A  gas  or  oil  heater  may 
properly  be  condemned,  for  it  vitiates  the  air  with  carbon 
monoxid,  aldehyds,  and  other  poisonous  products  which  are 
poured  directly  into  the  air. 

An  iron  stove  does  not  ventilate  a  room.  When  a  stove  is 
red  hot.  carbon  monoxid  may  pass  through  the  iron  into  the  air. 
A  hot-air  heater  must  necessarily  send  a  great  amount  of  air 
into  a  room.  The  purity  of  the  air  will  depend  upon  its  source. 
Heating  the  air  neither  adds  anything  to  it  nor  takes  anything 
from  it,  provided  the  furnace  does  not  leak  gas  or  ashes. 

A  radiator  heated  with  steam  or  hot  water  does  not  ventilate 
a  room.  A  cubic  foot  of  air  at  a  freezing  temperature  contains 
about  2  grains  of  moisture  when  it  is  saturated,  but  the  same 
air  can  hold  nearly  8  grains  when  it  is  heated  to  70°  F.  Satu- 
rated outdoor  air  at  a  freezing  temperature  will  have  a  humidity 
of  only  25  per  cent,  after  it  has  entered  a  heated  room.  It  is 
necessary  to  add  water  to  the  incoming  air  of  a  heated  room. 
This  may  be  done  by  means  of  a  pot  of  water  set  in  the  jacket  of 
a  hot-air  furnace  or  by  means  of  special  evaporators  placed  on 
the  backs  of  radiators. 

The  Health  Officer  and  Ventilation. — The  health  officer  sel- 
dom has  direct  control  over  ventilation,  for  there  are  no  fixed 
standards  of  the  purity  of  the  air  and  of  methods  of  ventilation. 
But  he  can  have  a  great  influence  by  educating  the  people  regard- 
ing the  value  of  fresh  air  and  the  methods  of  obtaining  it.  He 
can  also  act  as  adviser  of  those  who  have  charge  of  the  ventila- 
tion and  heating  of  schools,  churches,  meeting  halls,  and  other 
places  of  assembly. 


CHAPTER  XLI 

INDUSTRIAL  HYGIENE 

Control  of  Working  Conditions. — Some  occupations,  such  as 
farming,  are  popularly  known  to  be  healthful;  some,  such  as 
lead  working,  may  directly  produce  ill  health  and  disease;  and 
in  others,  such  as  mining,  there  is  a  great  risk  to  life  and  limb. 
Skilled  workmen  are  able  to  take  the  needful  precautions  against 
disease  and  accident,  and  to  secure  the  essential  comforts  of 
life  in  their  places  of  work;  but  unskilled  laborers  must  accept 
the  conditions  under  which  they  are  compelled  to  work.  The 
laws  are  now  requiring  employers  of  labor  to  provide  the  proper 
safeguards  for  the  life,  health,  and  comfort  of  their  workmen. 
The  enforcement  of  the  laws  rests  primarily  with  departments 
of  labor  and  factory  inspectors,  but  the  control  of  conditions 
which  directly  affect  the  life  or  health  of  workmen  is  within  the 
scope  of  the  activities  of  a  health  department. 

The  physical  welfare  of  workingmen  is  becoming  of  increased 
importance  to  a  health  officer  owing  to  at  least  four  factors : 

1.  There  has  been  a  great  expansion  of  industries  in  which 
poisonous  chemicals  are  used. 

2.  There  is  an  increasing  specialization  of  work  in  factories 
and  workshops.  A  man  is  assigned  to  a  particular  duty  which 
he  performs  over  and  over  through  the  entire  day.  He  is  ex- 
posed to  the  intensive  effect  of  unhealthful  influences  day  after 
day  without  change. 

3.  The  physical  effects  often  come  on  insidiously,  and  each 
workman  is  likely  to  think  that  he  is  immune. 

4.  There  is  an  increasing  employment  of  ignorant  workmen 
who  know  little  of  the  trade  dangers,  take  no  precautions,  and 
are  careless  or  indifferent. 

There  is  a  recognition  of  the  duty  of  employers  of  labor  to 
safeguard  their  workmen  against  industrial  hazards,  and  to  see 
that  they  get  the  protection  which  they  are  unable  or  unwiUing 
to  give  to  themselves.  Whatever  promotes  the  health  and 
vigor  of  laborers  benefits  the  employer.  The  excuse  is  no  longer 
valid  that  employers  cannot  afford  to  consider  the  health  and 
welfare  of  the  employed.  The  financial  cost  of  ill  health  result- 
ing from  a  trade  hazard  is  properly  chargeable  to  the  employers 
and  their  customers.     A  laborer  bears  his  share  of  the  burden 

477 


478  THE  HEALTH   OFFICER 

of  a  trade  hazard  when  he  loses  his  health  or  earning  capacity 

as  a  result  of  engaging  in  the  work. 

Classification. — The  subject  of  industrial  hygiene  may  be 
considered  under  three  divisions:  1,  occupational  disabihty;  2, 
factory  hygiene;  and  3,  workmen's  welfare. 

Disabilities  resulting  from  occupations  may  be  divided  into 
two  groups:  1,  occupational  diseases,  or  those  caused  by  dele- 
terious substances  which  the  workmen  handle;  and  2,  accidents, 
or  those  disabilities  caused  by  defective  processes  of  work. 

Occupational  diseases  are  classified  according  to  the  injuri- 
ous emanations  or  substances  given  off  by  the  materials  which 
are  handled  by  the  workmen.     These  emanations  consist  of: 

1.  Metallic  poisons. 

2.  Gases,  vapors,  and  fumes. 

3.  Chemicals,  either  liquid  or  solid. 

4.  Irritating  dusts. 

5.  Infectious  material. 

Metallic  Poisons. — The  metallic  poisons  which  are  of  special 
importance  to  a  health  officer  are  lead,  mercury,  arsenic,  and 
antimony.  Lead  is  used  in  the  manufacture  of  paints,  glass,  and 
storage-batteries,  and  lead-poisoning  occurs  in  over  a  hundred 
common  trades  and  occupations.  A  health  officer  investigating 
alleged  cases  of  industrial  poisoning  will  inquire,  first  of  all, 
whether  or  not  lead  in  any  form  is  used. 

Mercury  is  used  in  smelting  precious  metals,  in  the  manu- 
facture of  incandescent  Hght  bulbs,  thermometers,  and  barom- 
eters, and  in  the  felt  and  fur  industries. 

Arsenic  is  used  in  smelting,  in  the  manufacture  of  certain 
dyes  and  paints,  and  in  curing  furs. 

Antimony  is  a  constituent  of  type  metal,  and  poisoning  by  it 
sometimes  occurs  among  printers. 

Metallic  poisoning  usually  occurs  from  inhaling  the  dust  or 
fumes  from  the  metals,  from  their  transference  from  soiled  hands 
to  the  mouth,  and  sometimes  from  the  direct  absorption  of  the 
poisons  through  the  skin.  The  prevention  of  the  poisoning 
consists  in  the  use  of  devices  for  the  suppression  or  removal  of 
dust  and  fumes,  in  the  use  of  respirators  and  rubber  gloves, 
and  in  cleanliness  of  the  hands  and  clothes,  especially  before 
eating. 

Gases,  vapors,  and  fumes  are  given  off  during  processes  in 
which  hot  metals  or  chemicals  are  handled,  as  in  metal  casting. 
Painters  and  varnishers  working  in  closed  places  are  frequently 
overcome  by  the  vapors  of  wood  alcohol,  benzine,  or  gasolene. 
The  exhaust  from  gasolene  engines  may  produce  dizziness  and 
unconsciousness  from  the  presence  of  carbon  monoxid  in  the 


INDUSTRIAL   HYGIENE  479 

burned  gases.  When  cases  of  obscure  forms  of  poisoning  come 
to  the  attention  of  a  health  officer,  the  possibiHty  of  poisoning 
by  paints  and  varnishes  or  by  the  exhaust  of  engines  is  to  be 
considered. 

Chemicals  frequently  cause  eruptions  and  ulcers  on  the  skin. 
A  common  form  is  an  eruption  on  the  fingers  of  photographers 
caused  by  metol  in  the  developer.  One  of  the  most  important 
forms  of  chemical  poisoning  was  formerly  the  destruction  of 
the  bones  of  the  jaws  by  phosphorus  used  in  the  manufacture  of 
matches;  but  it  is  not  necessary  to  use  phosphorus,  and  most 
matches  do  not  now  contain  it. 

The  irritant  dusts  of  trades  usually  do  harm  in  direct  pro- 
portion to  the  hardness  and  sharpness  of  their  particles.  The 
most  harmful  forms  consist  of  metallic  particles,  such  as  those 
given  off  during  the  grinding  of  sharp  instruments.  Mineral 
dusts,  such  as  those  of  stone-cutting,  are  less  harmful.  Coal- 
dust  seems  to  do  little  harm,  although  the  lungs  of  miners  may 
be  black  with  it.  Dusts  of  animal  and  vegetable  origin  are 
usually  soft  and  do  little  harm. 

The  harmful  effects  of  irritating  dusts  occur  principally  in 
the  lungs,  and  the  principal  disease  which  results  is  tuberculosis. 
But  the  dust  is  only  one  factor  in  the  production  of  the  disease, 
and  cannot  produce  tuberculosis  except  in  connection  with  other 
influences,  such  as  bad  housing,  poor  food,  fatigue,  and  exposure 
to  previous  cases. 

The  prevention  of  the  diseases  caused  by  dust  consists  in 
the  use  of  respirators  by  the  workmen,  and  in  the  removal  of 
the  dust  by  means  of  hoods  and  suction  fans  which  take  away 
the  dust  as  fast  as  it  is  formed. 

The  principal  infectious  material  with  which  workmen  come 
in  contact  is  anthrax  spores  in  the  hides,  wool,  and  hair  taken 
from  infected  animals. 

Caisson  Disease. — A  disease  called  caisson  disease  is  some- 
times produced  in  those  who  work  under  an  increased  air-pres- 
sure, as  in  building  tunnels  under  rivers.  The  symptoms  are 
severe  pains  and  cramps,  and  are  caused  by  air-bubbles  which 
form  in  the  spinal  cord  when  the  air-pressure  is  lowered  too 
rapidly.  The  treatment  consists  in  subjecting  the  patient  to 
the  air-pressure  again,  and  then  lowering  the  pressure  slowdy. 

Accidents. — Three  great  factors  in  the  causation  of  indus- 
trial accidents  are:  1,  unguarded  machinery;  2,  fatigue;  and  3, 
the  carelessness  of  the  workmen  themselves. 

Examples  of  the  dangerous  machinery  for  which  an  inspect- 
ing health  officer  will  look  are  open  gear-wheels,  uncovered  re- 
volving shafts,  especially  tliose  having  protruding  bolts,  unpro- 


480  THE   HEALTH    OFFICER 

tected  knives,  and  hand-fed  presses  without  guards  or  guides. 
Three  preventive  measures  are:  1,  provision  for  stopping  the 
machinery  instantly;  2,  covering  shafts,  gear-wheels,  and  other 
moving  parts;  and  3,  the  use  of  an  individual  motor  for  driving 
each  machine. 

Fatigue  is  a  great  factor  in  causing  accidents.  A  tired 
workman  is  slow  to  respond  to  the  signs  of  danger,  and  many 
accidents  occur  simply  from  the  failure  of  the  fatigued  nervous 
system  to  act  with  its  usual  quickness.  There  is  an  increase  in 
the  number  of  accidents  in  each  hour  from  morning  to  noon. 
The  number  falls  during  the  hour  following  the  noon  rest  and 
increases  again  during  the  course  of  the  afternoon. 

After  all  possible  safeguards  against  accidents  have  been 
taken,  there  still  remains  the  uncertainty  of  the  action  of  the 
human  machine.  This  is  usually  ascribed  to  carelessness,  but 
many  careful  persons  are  naturally  slow  in  their  mental  actions, 
and  are  temperamentally  unfitted  to  work  with  dangerous 
machinery. 

The  use  of  alcohol  predisposes  a  workman  to  occupational 
diseases  and  accidents  both  by  making  him  dull  and  careless 
and  also  by  lowering  his  resistance  to  the  unhealthful  influences. 
Closely  related  to  fatigue  are  the  subjects  of  child  labor,  the 
emplo}'ment  of  women,  and  hours  of  labor. 

Reporting  Occupational  Disabilities. — There  is  great  need  of 
a  deeper  study  of  occupational  disabilities.  A  knowledge  of 
their  extent  and  nature  and  of  the  means  of  their  prevention 
depends  upon  individual  case  records  made  in  a  complete  man- 
ner by  a  uniform  method.  Such  records  are  necessary  in  com- 
paring conditions  in  various  places  and  occupations.  It  is 
necessary  to  secure:  1,  a  report  of  every  case;  2,  a  record  of  the 
conditions  in  the  factory  or  shop;  and  3,  a  statement  of  the 
exact  duties  performed  by  the  patient.  If,  for  example,  he  is  a 
laborer,  the  record  will  show  the  kind  of  work  in  which  he  is 
engaged. 

Factory  Hygiene. — The  principal  points  which  a  health  officer 
will  observe  in  estimating  the  hygienic  condition  of  a  factory 
are  as  follows: 

1.  Sanitary  conveniences:  Toilets — their  number,  accessi- 
bility, and  cleanliness.  Washrooms — their  location,  cleanliness, 
and  supplies  of  hot  water,  soap,  and  towels.  Place  for  hanging 
clothes;  separation  of  street  clothes  from  those  worn  during  work; 
each  individual  suit  to  have  sufficient  space  to  avoid  contact 
with  others,  and  the  transfer  of  lice  and  infection;  provision  for 
drying  wet  clothes;  the  use  of  individual  lockers.  Eating  rooms 
— cleanliness  and  conveniences. 


INDUSTRIAL    HYGIENE  481 

2.  Cleanliness:  Sweeping  to  be  done  out  of  working  hours. 
Spitting — spittoons  and  their  cleanliness. 

3.  Ventilation,  heating,  humidity,  and  odors:  Overheating 
and  high  humidity  are  common  faults.  Provision  for  suppress- 
ing and  removing  dust. 

4.  Lighting:  Avoidance  of  dense  shadows  and  of  glare  in  the 
eyes.  Much  fatigue  comes  from  eye-strain  caused  by  lights 
placed  on  a  level  with  the  eyes. 

5.  Drinking-water:  Its  purity,  coolness,  and  abundance;  pro- 
vision for  drinking-cups  or  fountains. 

Provision  for  Workmen's  Welfare. — It  is  to  the  interest  of 
the  employer  to  provide  for  the  comfort  and  welfare  of  his  work- 
men. Among  the  practical  means  which  may  be  used  are  the 
following : 

1.  Provision  for  seats,  and  adjusting  the  height  of  tables  in 
order  to  avoid  postural  strains,  backaches,  and  spinal  curvatures. 

2.  Rooms  for  rest  and  recreation. 

3.  Medical  examinations  of  the  workmen  on  their  entrance 
to  the  factory,  and  periodically  afterward;  and  the  adjustment 
of  the  workmen  to  the  work  for  which  they  are  adapted. 

4.  Provision  for  first  aid,  nursing  attendance,  and  beds  for 
the  sick  and  injured. 

5.  Follow-up  work  by  visitations  at  the  homes  of  the  work- 
men. 

6.  Educational  work  on  the  nature  of  special  dangers  and 
their  avoidance;  lunches;  recreation  during  the  noon  period,  and 
measures  to  avoid  fatigue;  the  proper  use  of  wash-rooms;  the 
avoidance  of  infection. 

Related  Subjects. — Industrial  hygiene  is  closely  related  to 
housing  conditions,  and  to  economics  and  sociology.  Whatever 
improves  the  financial  and  social  standing  of  workmen  improves 
their  strength  and  efficiency.  The  proper  use  of  wages  in  buy- 
ing food  and  clothes  and  in  securing  proper  housing  conditions 
has  a  far-reaching  effect  on  health.  The  advice  and  influence  of 
.a  health  officer  will  go  far  toward  securing  the  essential  condi- 
tions of  work  and  living  which  make  a  working  man  healthy, 
efficient,  and  contented. 
31 


CIL^PTER  XLII 

CAMP  SANITATION 

Knowledge  Required. — Camps  are  established  either  for 
emergency  housing  or  for  pleasure.  The  object  of  living  in  the 
open  or  in  a  temporary  shelter  in  preference  to  an  elaborate 
system  of  housing  is  either  to  avoid  expense  or  to  enjoy  a  primi- 
tive mode  of  living.  Those  who  conduct  a  camp  are  likely  to 
provide  a  meager  outfit,  and  to  manage  it  in  a  careless  manner, 
owing  to  the  freedom  from  the  restraints  of  civilized  society 
and  from  the  incentives  to  neatness  and  order  which  exist  in 
permanent  villages.  Many  persons  who  go  camping  are  igno- 
rant of  sanitation  and  untrained  in  sanitary  methods,  for  when 
they  are  at  home  they  do  no  kitchen  work,  they  obtain  their 
water  from  public  sources,  and  empty  their  sewage  into  a  public 
sewer;  and  when  they  are  in  camp  they  often  neglect  elementary 
sanitary  precautions.  They  do  this  largely  through  ignorance. 
The  management  of  a  camp  requires  a  degree  of  skill  and  sani- 
tary knowledge  which  is  not  necessarily  associated  with  a  gen- 
eral education.  Teachers,  ministers,  Y.  M.  C.  A.  workers,  and 
others  who  conduct  camps  often  need  instruction  regarding  the 
elementary  principles  of  camp  sanitation. 

Camps  for  laborers  are  especially  likely  to  be  unsanitary 
owing  to  the  ignorance  of  their  occupants  and  to  the  economy 
and  indifference  of  contractors  and  employers.  The  menace 
from  an  unsanitary  camp  is  recognized  by  the  Department  of 
Health  of  New  York  State,  and  Chapter  5  of  the  Sanitary  Code 
is  devoted  to  regulations  affecting  labor  camps.  A  special 
feature  of  the  code  is  that  requiring  a  permit  from  a  health  officer 
for  a  labor  camp  to  be  occupied  by  10  or  more  men  during  more 
than  six  days.  The  sanitary  control  of  a  labor  camp  by  the 
health  ofilicer  is  justified  by  the  necessity  that  laborers  shall  live 
in  it  under  conditions  which  are  not  of  their  own  choosing.  The 
fact  that  residence  in  other  forms  of  civilian  camps  is  usually 
voluntary  makes  possible  their  control  by  educational  means. 

The  general  points  to  be  considered  in  the  sanitation  of  a 
camp  are  its  location,  water-supply,  equipment,  and  manage- 
ment. An  experienced  camper  is  able  to  keep  himself  comfort- 
able and  healthy  in  an  unfavorable  locality  and  with  an  inade- 
quate outfit.  An  untrained  person  will  require  a  favorable  site 
482 


CAMP    SANITATION  483 

and  adequate  equipment.  A  common  fault  in  establishing  a 
camp  is  that  of  provicHng  an  equipment  that  is  inadequate  to 
the  needs  of  the  campers.  Inexperienced  campers  will  generally 
use  the  equipment  which  they  find  at  the  camp,  and  will  neglect 
the  measures  for  which  no  equipment  is  provided.  A  funda- 
mental principle  in  establishing  a  camp  is  to  provide  a  location 
and  an  equipment  that  will  make  the  management  of  sanitary 
affairs  as  easy  as  possible  for  inexperienced  campers. 

Location. — The  principal  hygienic  points  to  be  considered  in 
the  location  of  a  camp  are: 

1.  Accessibility,  including  means  of  transporting,  and  ease  of 
obtaining,  supplies. 

2.  The  soil,  its  porosity,  depth,  slope,  height  above  ground 
water,  and  area  available  for  the  disposal  of  human  wastes. 

3.  Sources  of  water-supply. 

4.  Shade  and  other  protection  from  the  sun  and  weather. 
.5.  Liability  to  contaminate  a  neighboring  water-supply. 

6.  Sources  of  contamination  in  the  neighborhood. 

7.  Freedom  from  flies  and  from  mosquitoes,  especially  the 
malarial  varieties. 

Water-supply. — The  water-supply  is  of  fundamental  im- 
portance in  the  sanitation  of  a  camp.  A  health  officer  will  con- 
sider its  source,  the  means  of  preserving  its  purity,  and  its  rela- 
tion to  the  sites  for  the  disposal  of  wastes.  If  a  well  or  spring  is 
the  source  of  water,  its  location  will  often  be  the  factor  which 
will  determine  the  location  of  the  other  equipment  of  the  camp. 

Equipment. — The  equipment  of  a  camp  consists  of  shelters, 
furnishings,  and  food  supplies.  A  health  officer  will  consider 
the  following  sanitary  points  regarding  the  construction  of  a 
shelter : 

1.  A  method  of  construction  and  a  state  of  repair  that  per- 
mit of  easy  cleaning. 

2.  A  floor  space  of  at  least  50  square  feet  per  person  sleeping 
in  the  shelter  in  order  to  permit  of  ventilation  and  to  prevent 
infection  by  breathing. 

3.  Means  of  ventilation.  While  canvas  may  permit  the 
passage  of  wind  through  its  meshes  on  dry,  windy  days,  it  is 
almost  air-tight  on  calm,  damp  days.  An  unventilated  tent 
may  be  as  stuffy  and  close  as  a  plastered  house.  Flaps,  win- 
dows, or  other  openings  are  necessary  for  ventilation. 

A  health  officer  is  particularly  interested  in  the  furnishings 
and  utensils  used  in  sleeping,  eating,  and  washing.  The  proper 
equipment  for  each  of  these  activities  will  be  found  in  definite 
parts  of  a  camp  if  it  is  properly  managed. 

A  common  fault  in  sleeping  quarters  is  that  of  overcrowding. 


484  THE   HEALTH    OFFICER 

A  space  of  at  least  3  feet  is  required  between  beds  in  order  to 
prevent  infection  by  means  of  droplets  of  saliva  and  mucus 
expelled  during  coughing,  or  sneezing,  or  loud  talking.  Addi- 
tional measures  for  preventing  infection  are: 

1.  Hanging  a  blanket  or  sheet  between  the  heads  of  adjacent 
beds. 

2.  Placing  the  head  of  one  sleeper  opposite  the  feet  of  the 
next. 

The  minimum  equipment  for  handling  food  and  for  eating 
will  include: 

'  1.  Containers  and  screens  for  protecting  food  against  dust, 
flies,  and  vermin. 

2.  Dish-pans  and  dish-cloths  for  washing  dishes. 

3.  Metal  garbage  pails. 

4.  Metal  water  pails. 

5.  Facilities  for  heating  water. 

The  minimum  equipment  for  washing  the  person  consists  of 
basins,  towels,  and  soap,  placed  in  a  definite  location  in  which 
the  waste-water  cannot  pollute  the  source  of  water-supply.  It 
is  wise  to  require  the  campers  to  bring  their  indi\'idual  basins, 
towels,  and  soap.  No  towel  at  all  is  preferable  to  one  that  is 
used  in  common. 

A  health  officer  inspecting  a  camp  will  notice  the  following 
points  regarding  the  food  supply: 

1.  Does  it  form  a  balanced  diet?  A  proper  food-supply  will 
contain — 

{a)  Cereal. 

(b)  Meat,  cheese,  or  other  animal  food. 

(c)  Vegetables. 

(d)  Fruit. 

(e)  Salt  and  pepper. 
(/)  Sugar. 

These  foods  can  be  made  into  appetizing,  wholesome  dishes  by 
a  person  who  possesses  an  aveage  degree  of  skill  in  cooking. 

2.  Will  the  food  keep  fresh  with  the  facilities  at  the  camp? 
Wholesome  foods  that  will  keep  fresh  may  be  obtained  in  dried 
form  or  in  sealed  packages. 

3.  Can  the  foods  be  cooked  readily  with  the  utensils  at  the 
camp?  Desserts  and  dishes  requiring  considerable  time  and 
skill  to  prepare  are  out  of  place  in  an  ordinary  camp. 

A  health  officer  will  also  investigate  the  source  of  milk- 
supply,  and  will  advise  its  pasteurization  at  the  camp  if  its 
quality  and  grade  are  not  above  suspicion. 

Management. — The  most  important  element  in  camp  man- 
agement is  the  prevention  of  the  transfer  of  human  excretions 


CAMP    SANITATION  485 

and  wastes  from  one  person  to  another.  The  soil,  water,  and 
air  of  uninhabited  places  are  naturally  healthful,  and  will  remain 
so  if  they  are  protected  from  human  pollution.  The  disposal  of 
human  wastes  requires  as  constant  attention  as  the  preparation 
of  food.  The  management  of  the  sanitation  of  a  camp  consists 
principally  of  two  classes  of  measures: 

1.  Those  for  general  cleanliness,  or  the  disposal  of  attenuated 
waste  matter. 

2.  The  disposal  of  gross  wastes,  such  as  garbage  and  sewage. 
Cleanliness. — The  dirt  which  a  sanitarian  seeks  to  prevent  or 

remove  is  that  which  comes  directly  from  human  beings.  No 
sanitary  effect  is  usually  produced  by  outdoor  dust,  the  soil  of 
fields  and  swamps,  decaying  vegetable  matter,  or  the  excretion 
of  wild  animals.  There  are  great  opportunities  for  the  transfer 
of  infectious  material  by  means  of  dirty  beds,  soiled  towels, 
dusty  floors,  and  unclean  dining  tables.  A  person  does  not 
usually  infect  himself  by  means  of  his  own  dirt  and  excretions, 
but  he  may  infect  persons  with  whom  he  comes  in  contact.  The 
danger  of  infection  is  in  direct  proportion  to  the  closeness  of 
contact  of  the  occupants  of  the  camp  with  one  another.  The 
general  cleanliness  and  good  order  of  a  camp  are  fair  indications 
of  the  care  which  the  occupants  take  in  the  disposal  of  their 
excretions  and  in  all  other  sanitary  matters.  A  health  officer 
inspecting  a  camp  will  pay  particular  attention  to  the  cleanhness 
of  every  part. 

Water-supply. — If  the  source  of  the  water-supply  is  a  well, 
spring,  or  stream  on  the  camp  site,  the  following  precautions  are 
necessary  for  its  protection : 

1.  Locating  the  buildings  so  that  their  drainage  will  not  reach 
the  water. 

2.  Installing  a  trough  or  gutter  to  conduct  the  overflowing 
water  away  from  the  source  of  supply. 

3.  Disposing  of  wastes  at  a  place  remote  from  the  water- 
supply. 

4.  Prohibiting  washing  near  the  source  of  water. 

Sleeping  Quarters.— A  health  officer  will  take  note  of  the 
following  conditions  in  the  sleeping  quarters: 

1.  Cleanliness. 

2.  Overcrowding. 

3.  Dryness. 

4.  Airing  the  bedding  during  the  day. 

5.  Open  windows,  doors,  or  tent  flaps  for  ventilation  during 
the  night. 

Kitchen. — The  principal  kitchen  conditions  which  a  health 
ofiicer  will  investigate  are  as  follows: 


486  THE    HEALTH    OFFICER 

1.  Cleanliness  of  the  utensils,  tables,  and  floors. 

2.  Protection  of  food  from  dust,  flies,  and  vermin. 

3.  Cleanliness  of  garbage  pails.  They  are  to  be  scrubbed 
daily  with  hot  water  and  soap,  both  inside  and  outside. 

4.  Cleanliness  of  the  ice-box.  Its  inside  is  to  be  scrubbed  at 
least  twice  a  week. 

5.  Cleanliness  of  the  hands  and  finger-nails  of  the  cook. 
Facilities  for  washing  the  hands  are  to  be  provided  separate 
from  those  used  in  washing  dishes. 

6.  The  quarters  and  toilet  facilities  for  the  cook. 

7.  Cleanliness  of  dish-cloths.  They  are  to  be  washed  in 
boiling  water.  An  odor  about  a  dish-cloth  is  an  indication  that 
it  is  dirty  and  unfit  for  use. 

8.  The  method  of  washing  dishes  and  their  cleanliness.  A 
test  for  cleanliness  is  their  odor.  Cover  a  dish  for  a  few  moments 
and  then  smell  of  its  inside.  If  there  is  an  unpleasant  odor,  the 
dish  is  not  clean. 

A  simple  sanitary  method  of  washing  dishes  is  as  follows: 

1.  Provide  two  pans  of  water — the  first  moderately  hot,  the 
second  boiling  hot. 

2.  Wash  the  dishes  in  pan  No.  1  in  the  ordinary  way. 

3.  Immerse  the  dishes  in  pan  No.  2  in  order  to  sterilize  them. 

4.  Stand  the  dishes  on  edge  or  upside  down  so  that  they  will 
dry  themselves.  Wiping  them  increases  the  danger  of  intro- 
ducing dirt  and  infectious  material  from  the  hands  and  towels. 

Disposal  of  Human  Wastes. — Camp  wastes  may  be  divided 
into  rubbish,  garbage,  waste  water,  and  human  excretions. 

A  ready  means  of  disposing  of  rubbish  is  to  burn  it.  A  large 
part  of  garbage  may  be  dried  and  burned.  An  easy  way  to  dis- 
pose of  tin  cans  is  to  pound  them  flat,  burn  them  in  the  rubbish 
fire,  and  afterward  bury  them. 

Garbage  that  is  water-soaked  is  likely  to  putrefy  or  ferment 
and  become  breeding-places  for  flies.  An  efficient  means  of  dis- 
posing of  it  is  to  empty  it  into  a  hole  2  or  3  feet  deep  and  to 
cover  each  portion  at  once  out  of  the  reach  of  flics. 

Waste-water  consists  principally  of  that  from  the  kitchen 
and  that  used  in  washing  the  hands  and  in  bathing.  Three 
simple  methods  of  disposing  of  it  are: 

1.  Emptying  it  into  a  pit  filled  with  stones.  The  pit  acts 
like  a  stone  bed  in  a  sewage  disposal  plant. 

2.  Emptying  it  into  a  pit  and  covering  the  sediment  with  a 
layer  of  soil  each  day. 

3.  Collecting  it  in  a  pail  or  barrel  and  emptying  it  in  a  re- 
mote part  of  the  camp.  Scrub  the  inside  of  the  pail  or  barrel 
after  emptying  it. 


CAMP   SANITATION  487 

Disposal  of  Human  Excretions.— A  sanitary  measure  in  which 
campers  are  frequently  lax  is  the  disposal  of  human  excretions. 
Three  simple  methods  of  their  disposal  are : 

1.  Depositing  the  excretions  in  a  deep,  narrow  trench  and 
covering  them  at  once  with  a  layer  of  earth. 

2.  Depositing  them  in  a  simple  latrine  made  by  digging  a 
trench  18  inches  wide  and  2  or  3  feet  deep,  and  placing  over  it 
a  box  fitting  fly-tight,  with  a  self-closing  seat. 

3.  A  pail  system  of  disposal,  the  pails  to  be  placed  in  a  fly- 
tight  box,  their  contents  buried  daily,  and  the  pails  themselves 
washed.  The  helpers  are  to  be  provided  with  a  latrine  as  sani- 
tary as  the  one  used  by  the  campers. 

It  is  important  that  a  camp  be  left  in  a  sanitary  condition, 
and  especiaUy  that  all  excretions  be  buried  where  they  are  in- 
accessible to  flies  and  cannot  pollute  the  water  or  surface  soil. 

Communicable  Diseases. — Those  who  manage  a  camp  often 
neglect  to  make  provision  for  the  isolation  and  control  of  per- 
sons who  have  a  communicable  disease.  It  is  particularly 
necessary  to  recognize  a  case  in  the  early  stages  of  the  disease 
and  to  isolate  it  at  once.  A  well-ordered  camp  will  have  an 
extra  tent,  or  at  least  a  bed,  in  which  a  suspicious  case  may  be 
isolated.  The  Sanitary  Code  of  New  York  State  requires  the 
person  in  charge  of  a  labor  camp  to  report  cases  of  communicable 
disease  that  occur  in  it. 


CHAPTER  XLIII 

CHILD  HYGIENE 

Infant  Mortality  Rates. — An  infant  mortality  rate  is  the 
number  of  deaths  among  each  1000  infants  under  one  year  of 
age.  The  number  of  infants  under  one  year  old  in  a  com- 
munity is  reckoned  as  the  number  of  births  in  that  community 
during  the  year.  An  infant  mortality  rate  is,  therefore,  the 
annual  number  of  deaths  of  infants  under  one  year  old  among 
each  1000  births  occurring  annually  in  that  community. 

The  death-rate  for  persons  of  all  ages  in  New  York  City 
was  nearly  30  per  1000  inhabitants  up  to  about  the  year  1890. 
The  greatest  death-rate  for  any  age  group  was  that  of  infants 
under  one  year  old,  among  whom  it  was  nearly  300,  or  ten  times 
the  rate  for  the  whole  city.  The  death-rate  of  New  York  City 
for  1917  was  approximately  14,  while  the  infant  mortality  rate 
was  slightly  under  100.  The  greatest  saving  in  life  has  been 
among  infants,  and  the  greatest  factor  in  the  work  has  been  the 
City  Department  of  Health. 

Child  hygiene  work  was  begun  in  the  larger  and  more  pro- 
gressive cities.  There  complete  surveys  of  the  field  ha\'e  been 
made,  and  methods  of  work  have  been  developed  and  standard- 
ized. Wherever  the  w^ork  has  been  extended  to  the  smaller 
cities  and  to  villages,  the  results  have  been  great.  Although 
environmental  conditions  are  far  more  favorable  to  children  in 
the  country  than  to  those  in  the  city,  yet  the  personal  elements 
are  the  same  in  both  places,  and  rural  mothers  need  instruction 
and  supervision  quite  as  much  as  those  in  the  city.  If  the  in- 
fant mortality  rate  in  New  York  City  is  below  100,  that  in  a 
small  city,  or  village,  or  rural  district  should  be  below  50,  and 
can  be  reduced  to  that  figure  by  an  apphcation  of  the  same  prin- 
ciples that  are  applied  in  the  city.  It  is  the  duty  of  every  health 
officer  to  promote  the  work  of  child  hygiene.  If  he  fails  to  do 
so,  he  neglects  one  of  his  greatest  fields  of  usefulness.  The 
need  for  the  work  is  universal,  and  exists  in  the  country  as  well 
as  in  the  cities.  One-fifth  of  all  deaths  at  all  ages  occur  in  per- 
sons under  one  year  of  age,  and  one-third  occur  in  those  under 
five  years  of  age. 

Organization  of  Rural  Child  Hygiene  Work. — Child  hygiene 
work  cannot  be  done  in  a  formal,  perfunctory  way  as  is  possible 
in  establishing  quarantines  and  suppressing  nuisances.  A  health 
488 


CHILD    HYGIENE  489 

officer  will  accomplish  little  simply  by  visiting  sick  children  and 
giving  prescriptions  and  rapid-fire  advice  to  mothers.  Even  a 
system  of  medical  inspections  will  reach  only  the  babies  that  are 
already  sick.  Effective  work  can  be  done  only  by  reaching  the 
babies  while  they  are  well,  and  by  teaching  the  mothers  how  to 
prevent  their  babies  from  becoming  sick.  The  greater  part  of 
the  work  is  educational,  and  must  be  done  through  personal 
attention  to  the  individual  mothers.  The  staff  that  is  essential 
must  include,  first,  a  public  health  nurse,  and  second,  a  group 
of  intelligent  women  who  will  provide  the  nurse  with  supplies 
and  create  public  sentiment  in  favor  of  the  work. 

A  practical  method  of  starting  child  hygiene  work  in  a  small 
city  or  a  rural  community  is  that  the  health  officer  take  the 
following  steps: 

1.  Arouse  the  interest  of  a  group  of  women  who  will  form 
an  organization  to  promote  and  finance  the  work  until  the 
municipality  is  ready  to  assume  it. 

2.  Secure  the  service  of  a  nurse.  Her  service  a  part  of  the 
time  may  be  sufficient  at  the  outset. 

3.  Make  arrangements  for  the  medical  examination  and 
supervision  of  the  children.  The  health  officer  and  the  prac- 
tising physicians  of  the  community  will  find  that  the  experience 
and  knowledge  gained  from  the  work  will  repay  them  for  the 
time  and  efforts  which  they  give  to  it. 

When  a  nurse  begins  work  in  a  new  field,  she  will  adopt  the 
following  order  of  procedure : 

1.  Obtain  a  list  of  babies  from  the  registrar. 

2.  Visit  the  mothers  in  their  homes  and  observe  the  condi- 
tion of  the  babies. 

3.  Assist  the  mothers  in  the  care  of  the  babies  that  are  sick 
or  below  a  normal  physical  standard. 

4.  Arrange  for  meetings  of  groups  of  mothers. 

5.  Establish  an  infant  welfare  station  after  she  has  become 
familiar  with  the  field. 

Lines  of  Work. — Child  hygiene  work  is  divided  naturally 
into  four  divisions,  according  to  the  ages  of  the  children,  as 
follows : 

1.  Prenatal  care  of  the  mothers. 

2.  Infant  welfare  from  birth  to  two  years. 

3.  Work  during  the  preschool  age,  from  the  second  to  the 
sixth  year. 

4.  Medical  inspection  of  school  children. 

A  health  officer  will  keep  these  four  groups  in  mind.  He 
will  usually  begin  his  activity  among  the  infant  group,  and  will 
extend  it  to  the  other  groups  as  the  work  develops. 


490  THE  HEALTH   OFFICER 

Prenatal  Care  of  Mothers. — Forty  per  cent,  of  all  deaths 
among  infants  are  due  to  conditions  which  existed  among  moth- 
ers before  the  births  of  their  children.  The  principal  conditions 
which  cause  mothers  to  give  birth  to  weakling  babies  are: 

1.  Disease,  especially  tuberculosis  and  syphilis;  2,  overwork; 
3,  poor  nourishment;  4,  lack  of  care;  5,  ignorance  of  the  common 
signs  of  danger. 

The  remedy  for  these  conditions  includes  the  following 
provisions: 

1.  Personal  instruction  and  supervision  of  expectant  mothers 
by  the  public  health  nurse. 

2.  Hospital  care  preceding,  during,  and  after  the  birth  of  the 
child. 

3.  Adequate  medical  treatment. 

4.  Improvement  of  the  conditions  of  living  and  working, 
both  at  home  and  also  in  factories  and  other  places  of  employ- 
ment. 

5.  Education  and  instruction. 

6.  The  instruction  and  supervision  of  midwives  and  amateur 
nurses. 

The  health  officer  and  nurse  will  deal  with  each  mother 
individually,  and  will  promote  her  health  and  strength  either  by 
private  means,  or  by  the  assistance  of  neighbors,  or  through 
public  agencies.  The  special  value  of  the  nurse  in  these  cases 
is  that  she  is  the  authorized  agent  who  is  charged  with  the  duty 
of  securing  the  proper  attention  for  the  expectant  mother.  The 
proper  care  can  usually  be  had  in  any  community  if  some  one  is 
determined  to  get  it  for  the  mother. 

It  is  no  longer  valid  to  excuse  the  death  of  a  baby  by  saying 
that  the  infant  was  born  a  weakling.  The  causes  of  the  weak- 
ness are  known,  and  are  preventable  in  most  cases.  The  re- 
sponsibility for  the  ill  health  of  the  mother  is  upon  society  quite 
as  much  as  upon  the  mother  herself.  It  is  the  duty  of  every 
community  to  make  public  provision  for  expectant  mothers  in 
order  that  children  may  be  born  strong  and  vigorous.  The 
work  of  the  public  health  nurse  in  bringing  concrete  cases  to 
the  attention  of  officeholders  and  of  the  public  is  an  efficient 
means  of  arousing  the  public  conscience  regarding  child  wel- 
fare. 

Midwives  and  Amateur  Nurses. — The  control  of  midwives 
has  a  direct  effect  upon  the  health  and  vigor  of  both  mothers 
and  their  infants.  A  considerable  proportion  of  women  are 
attended  by  midwives  before,  during,  and  after  childbirth,  but 
there  has  been  little  control  o\'er  midwives  except  in  the  larger 
cities.     The   sanitary   code   of   New   York    State,    Chapter   4, 


CHILD    HYGIENE  491 

prescribes  the  qualifications  of  midwives,  and  requires  that  every 
woman  who  practices  midwifery  shall  be  licensed  by  the  state, 
and  shall  be  registered  with  the  local  registrar  of  vital  statistics. 
The  New  York  State  Department  of  Health  has  undertaken  the 
work  of  having  its  public  health  nurses  visit  and  supervise  the 
midwives,  and  to  instruct  them  in  their  legal  duties.  The  nurses 
particularly  instruct  them  in  the  necessity  of  calling  a  physician 
when  an  abnormality  is  found  in  either  the  mother  or  child. 
When  a  nurse  investigates  a  midwife,  the  principal  points  which 
she  will  consider  are  as  follows : 

1.  Personal  character  and  general  intelHgence. 

2.  Cleanliness  of  her  person,  her  home,  and  her  midwifery 
outfit. 

3.  The  possession  of  instruments  or  drugs  which  can  be 
properly  used  only  by  a  physician. 

4.  Ability  and  willingness  to  apply  preventive  measures 
against  ophthalmia  neonatorum. 

5.  The  general  standard  of  her  work,  and  the  health  and 
vigor  of  the  women  and  infants  whom  she  has  attended. 

6.  Her  reputation  for  calling  a  physician  in  difficult  and 
abnormal  cases. 

7.  Her  record  for  reporting  births  to  the  registrar  of  vital 
statistics. 

The  influences  which  the  State  Department  of  Health  can 
bring  to  bear  upon  a  midwife  are: 

1.  Publicity  of  its  approval  or  condemnation  of  her  work. 

2.  Revocation  of  her  license. 

3.  Prosecution  for  illegal  practice  or  for  neglect  of  cases. 

A  health  officer  can  render  valuable  assistance  to  the  State 
Department  of  Health  in  its  investigation  of  midwives.  A 
public  health  nurse  can  investigate  the  midwives  and  inform  the 
State  Department  of  Health  regarding  them.  She  can  also 
secure  their  co-operation  and  support  in  the  prenatal  care  of 
mothers  and  in  the  work  of  infant  welfare  stations.  Experi- 
ence demonstrates  that  midwives  will  co-operate  with  the  public 
health  nurse  when  they  find  that  the  nurse  is  not  critical,  but  is 
helpful. 

Americans  have  a  system  of  caring  for  women  before  and 
after  childbirth  by  untrained  amateur  nurses  who  do  the  house- 
work, care  for  the  mother  and  baby,  and  do  everything  else 
that  a  midwife  does  except  that  a  physician  is  expected  to  be 
present  during  the  actual  delivery  of  the  child.  The  instruc- 
tion and  control  of  these  nurses  is  a  problem  which  is  difficult 
and  unsolved.  If  a  public  health  nurse  is  tactful  she  can  do 
much  along  two  lines: 


492  THE   HEALTH    OFFICER 

1.  She  can  secure  the  confidence  and  co-operation  of  the 
nurses  and  educate  them  in  their  duties. 

2.  She  can  educate  mothers  regarding  the  proper  care  which 
they  may  expect  from  the  nurses. 

Infant  welfare  activities  embrace  those  relating  to  infants 
from  birth  to  the  age  of  two  years.  The  work  was  originally 
the  care  of  sick  babies,  but  it  is  now  primarily  the  prevention  of 
sickness,  and  the  promotion  of  growth  and  vigor  among  infants. 
It  includes  an  improvement  in  the  social  and  economic  condi- 
tions of  the  homes,  for  the  ability  of  parents  to  provide  the 
proper  care  for  their  children  depends  largely  upon  their  finan- 
cial, social,  educational,  and  moral  states.  It  is  closely  related 
to  housing,  hours  of  labor,  racial  habits,  and  the  control  of  the 
sale  of  alcoholic  liquors.  It  requires  the  co-operation  of  churches, 
charitable  societies,  schools,  civic  clubs,  and  other  organiza- 
tions for  improving  the  living  conditions  of  the  race.  But  the 
problem  of  infant  welfare  is  primarily  medical,  and  the  work 
is  nearly  always  done  under  the  auspices  of  a  health  department, 
either  local,  state,  or  national. 

Causes  of  Infant  Mortality. — The  causes  of  sickness,  abnor- 
malities, and  lack  of  development  among  infants  may  be  deter- 
mined from  a  study  of  the  causes  of  death,  for  the  proportion  of 
deaths  from  various  causes  is  about  the  same  as  the  proportions 
of  debilitating  conditions.  The  proportions  of  the  various 
causes  of  infant  mortality  in  New  York  City  are  as  follows: 

Per  cent. 

Congenital  conditions 40 

Diarrheal  conditions 25 

Respiratory  conditions 22 

Contagious  diseases 4 

All  other  causes 9 

Total 100 

Congenital  conditions  are  discussed  in  the  paragraph  on  the 
prenatal  care  of  mothers,  page  490. 

A  health  officer  will  keep  in  mind  that  the  principal  causes 
of  diarrheal  conditions  and  digestive  disturbances  are  improper 
feeding,  flies,  and  uncleanliness. 

The  principal  factors  relating  to  the  healthfulness  of  an  in- 
fant's food  are — 

1.  Its  original  composition. 

2.  Its  state  regarding  fermentation,  and  the  development  of 
unwholesome  products. 

3.  Its  infection  with  the  specific  organisms  of  intestinal  dis- 
eases. 

Breast  milk  meets  these  conditions  so  perfectly  that  it  is  in 


CHILD    HYGIENE  493 

a  class  by  itself.  It  is  adapted  by  nature  to  the  needs  of  the 
child;  it  is  fresh  and  uncontaminated ;  and  its  direct  transfer  from 
the  breast  to  the  infant's  stomach  prevents  the  entrance  of  the 
organisms  of  intestinal  diseases.  One  of  the  great  objects  of 
the  prenatal  care  of  mothers  is  their  education  in  the  care  of 
their  breasts,  and  the  adjustment  of  their  home  lives  in  order  that 
they  may  nurse  their  children. 

Artificial  Feeding. — The  substitutes  for  mother's  milk  may 
be  classed  as  follows: 

1.  Cow's  milk. 

2.  Goat's  milk. 

3.  Condensed  milk. 
,    4.  Dried  milk. 

5.  Proprietary  baby  foods. 

Cow's  milk  is  the  most  available  substitute  for  mother's 
milk.  It  is  a  satisfactory  substitute  when  it  is  produced  accord- 
ing to  the  methods  required  under  an  efficient  system  of  milk 
inspection  ("page  362).  The  principal  modification  which  it 
requires  is  its  dilution  with  plain,  sterile  water.  Milk  rich  in 
cream  is  not  desirable  for  infant  feeding.  The  so-called  curds 
passed  by  infants  often  consist  of  undigested  fat.  The  mixed 
milk  from  large  dairies  is  almost  uniform  in  composition. 

The  pasteurization  of  milk  is  usually  necessary  in  infant 
feeding  unless  certified  milk  or  milk  of  equally  good  quality  is 
used.  The  principal  hygienic  effect  of  pasteurization  is  to  de- 
stroy the  specific  germs  of  human  diseases  that  may  be  in  the 
milk.  It  also  improves  the  keeping  qualities  of  milk  by  destroy- 
ing many  of  the  organisms  of  fermentation.  Its  effect  on  the 
composition  of  milk  may  be  somewhat  harmful,  but  this  effect 
is  negligible  if  the  pasteurizing  temperature  is  kept  below  150°  F. 

Goat's  milk  can  scarcely  be  distinguished  from  cow's  milk  as 
an  infant  food.  There  are  certain  advantages  in  the  use  of  goat's 
milk,  especially  for  persons  of  moderate  financial  means.  A 
goat  costs  little;  it  is  cleanly,  and  requires  only  a  small  space;  it 
will  thrive  on  coarse  food,  such  as  weeds  and  shrubs;  it  is  not 
subject  to  tuberculosis;  and  it  may  be  milked  several  times  a 
day  without  harm.  A  mother  may  keep  a  goat  in  the  back  yard, 
and  at  each  feeding  she  may  draw  sufi&cient  milk  and  give  it  to 
the  baby  at  once  without  preparation  except  to  dilute  it.  It  is 
desirable  that  a  health  officer  should  encourage  the  use  of  goats 
as  a  supply  of  milk  for  infant  feeding. 

Condensed  milk  is  undesirable  as  infant  food  on  account  of 
its  usual  high  percentage  of  sugar  and  of  the  changes  in  com- 
position produced  by  the  process  of  evaporation.  Yet  it  is  pref- 
erable to  ordinary  market  milk  which  is  of  an  impure  quality. 


494  THE   HEALTH    OFFICER 

]\Iilk  evaporated  to  a  dry  powder  is  a  healthful  food  for 
infants.  Its  use  will  be  a  great  step  in  solving  the  problem  of 
providing  a  food  for  infants. 

Proprietory  infant  foods  have  no  advantage  over  plain  milk 
or  condensed  milk.  They  usually  consist  largely  of  cereal  flour, 
and  are  designed  to  be  added  to  milk.  Some  contain  milk 
powder.  When  they  are  used  alone,  nutritional  disturbances, 
such  as  marasmus,  scurvy,  and  rickets,  are  almost  sure  to 
develop. 

It  is  necessary'  that  a  health  officer  should  know  what  sub- 
stitutes for  mother's  milk  are  available  in  his  community;  and 
to  promote  the  use  of  clean,  fresh  milk  for  infant  feeding. 

Infectiousness  of  Infantile  Diarrhea. — A  large  proportion  of 
the  diarrheas  of  infants  are  due  to  special  organisms  which  are 
found  with  the  bowel  movements  of  the  sick  and  are  transferred 
from  the  sick  to  the  well  by  means  of  flies  and  unclean  hands, 
dishes,  and  clothing.  A  necessary  measure  in  preserving  the 
health  of  an  infant  is  to  protect  it  and  its  food  from  house-flies. 
Another  measure  is  cleanliness  of  the  hands  of  the  mother  and 
of  everything  else  that  touches  the  child.  It  is  especially  neces- 
sary that  the  mother  observe  the  following  rules  for  the  care  of 
soiled  diapers  and  underwear: 

1.  Protect  them  from  house-flies  until  they  can  be  washed. 

2.  Boil  them  during  some  stage  of  the  washing  process. 

3.  Dispose  of  the  wash-water  in  such  a  way  that  flies  cannot 
have  access  to  it. 

4.  Wash  the  hands  immediately  after  handling  soiled 
articles  (page  265). 

The  efl'ect  of  heat  and  humidity  in  producing  infantile  dis- 
eases is  principally  indirect  and  secondary  through  flies  and  fer- 
mentation. Flies  are  especially  numerous  and  active  during  hot 
weather.  The  processes  of  fermentation  are  promoted  by  heat 
and  moisture,  as  is  seen  in  the  prevalence  of  molds  during  hot, 
humid  weather.  If  a  baby's  food  is  kept  pure  and  fresh,  and  the 
baby  is  protected  from  flies  and  other  sources  of  infection,  hot 
weather  has  little  effect  on  the  infant's  health. 

Nutritional  Disturbances. — It  is  important  that  a  health 
officer  should  bear  in  mind  the  four  conditions  (1)  malnutrition, 
(2)  marasmus,  (3)  scurvy,  and  (4)  rickets.  All  these  conditions 
are  usually  associated  with  arrest  of  growth,  loss  of  weight,  and 
increased  susceptibility  to  infections  and  other  influences  which 
have  little  effect  on  a  normal  child.  There  may  be  the  special 
signs  of  scurvy  or  rickets  in  the  bones,  skin,  and  mucous  mem- 
branes. Some  afTected  infants  may  appear  to  be  fat,  but  they 
show  a  lack  of  muscular  development  and  strength.     The  con- 


CHILD    HYGIENE  495 

ditions  are  often  associated  with  chronic  diseases,  especially  syph- 
ilis and  tuberculosis. 

Simple  malnutrition  and  marasmus  are  due  either  to  an  in- 
sufficient amount  of  food,  or  to  a  diet  which  is  decidedly  un- 
balanced, as,  for  example,  condensed  milk  containing  an  excess 
of  sugar  and  a  deficiency  of  protein. 

Scurvy  seems  to  be  caused  principally  by  a  deficiency  of  the 
water-soluble  vitamins,  and  may  be  cured  by  giving  the  juices  of 
oranges  or  other  fruits. 

Rickets  seems  to  be  caused  principally  by  a  deficiency  of 
fat-soluble  vitamins,  and  is  cured  by  the  use  of  fresh  milk,  cod- 
liver  oil,  or  other  articles  containing  an  abundance  of  fat-soluble 
vitamins  (page  395). 

An  encouraging  feature  in  all  conditions  depending  primarily 
on  nutritional  disturbances  is  that  the  infants  recover  promptly 
and  completely  when  they  are  properly  fed.  There  are  three 
simple  principles  to  be  observed: 

1.  Give  the  proper  quantity  of  food. 

2.  Use  fresh  milk  as  the  principal  article  of  diet. 

3.  Offer  the  child  the  juice  of  an  orange  or  other  fruit  daily. 
If  the  juice  is  needed,  the  infant  will  take  it  greedily. 

One  of  the  most  efficient  activities  of  a  public  health  nurse 
is  to  discover  infants  who  suffer  from  arrested  development;  to 
give  advice  regarding  their  feeding;  and  to  secure  treatment  for 
those  who  suffer  from  chronic  infections. 

Respiratory  Diseases. — The  two  principal  avenues  for  the 
entrance  of  infectious  organisms  into  the  bodies  of  infants  are 
the  mouth  and  the  nose;  and  the  principal  organs  which  become 
infected  are  those  of  digestion  and  those  of  respiration. 

The  principal  source  of  respiratory  infections  in  infants  is 
their  contact  with  persons  who  have  colds  (page  243).  Common 
means  of  infecting  babies  with  the  organisms  of  respiratory  dis- 
eases are : 

1.  Hugging  and  kissing  them  by  those  who  have  colds. 

2.  Unclean  clothing. 

3.  Infectious  dust. 

4.  The  direct  transfer  of  saliva  by  such  means  as  putting 
spoons  and  feeding  bottles  to  the  lips  in  order  to  test  the  food; 
wiping  the  baby's  nose  with  another  person's  handkerchief;  and 
wiping  the  baby's  face  with  a  towel  or  handkerchief  that  is 
moistened  with  saliva. 

A  common  cause  of  respiratory  diseases  of  infants  is  their 
exposure  to  dust  from  human  sources,  especially  to  that  which 
contains  organisms  from  dried  sputum  as  a  result  of  spitting  on 
the  floor.     The  overcrowding  of  rooms  is  usually  associated 


496  THE  HEALTH   OFFICER 

with  human  dirt  and  dust.  It  is  also  associated  with  poor  venti- 
lation, overheating,  and  increased  opportunity  to  exposure  to 
persons  having  colds. 

Deahng  with  congenital,  digestive,  and  respiratory  condi- 
tions constitutes  nine-tenths  of  infant  welfare  work.  Health 
officers  and  public  health  nurses  who  are  efficient  in  these  lines 
of  work  will  also  be  efficient  in  dealing  with  other  infantile  con- 
ditions which  require  their  attention. 

Methods  of  Infant  Welfare  Work. — If  an  infant  does  not 
thrive,  a  remedy  that  suggests  itself  is  to  take  the  child  from  its 
home  and  place  it  in  an  institution  where  there  are  facilities  for 
its  care.  This  plan  has  been  tried  thoroughly,  and  has  been  a 
failure.  Nothing  has  been  found  to  take  the  place  of  a  mother 
or  foster-mother  in  a  pri\'ate  home.  The  death-rate  among 
infants  in  the  best  institutions  is  far  higher  than  that  among 
babies  in  the  tenement  homes.  Individual  care  in  a  private 
home  gives  far  better  results  than  care  in  an  institution,  except 
during  an  acute  illness. 

The  responsibility  for  the  care  of  infants  in  private  homes 
rests  upon  the  individuals  who  act  as  mothers  to  the  children. 
Infant  welfare  work  consists  essentially  in  the  education  of  each 
mother.  Home  visitation  and  instruction  by  the  public  health 
nurse  is  essential  in  saving  the  lives  and  promoting  the  health 
of  babies;  but  that  work  itself  is  but  30  per  cent,  efficient,  for 
there  still  remains  the  problem  of  persuading  the  mother  to  carry 
out  the  instructions.  A  mother  whom  the  nurse  visits  will  heed 
the  advice  of  neighbors  who  follow  the  old-time  methods  and 
consider  the  new  ways  to  be  unnecessary  and  unproved  innova- 
tions. The  nurse's  full  success  will  come  when  the  women  of  a 
community  begin  to  talk  about  her  methods,  to  seek  her  advice. 
The  present  great  success  of  infant  welfare  work  in  New  York 
City  is  due  largely  to  the  fact  that  the  people  generally  believe 
in  it  and  accept  it  just  as  they  accept  the  work  of  the  public 
schools.  Infant  welfare  work  is  a  community  problem  as  well 
as  an  individual  one.  Community  infant  welfare  work  consists 
in  (1)  field  work  among  needy  mothers,  and  (2)  that  among 
educated  people  of  financial  means  who  support  the  field  work. 

The  common  field  activities  in  infant  welfare  work  are  as 
follows  : 

1.  Public  health  nursing. 

2.  Mothers'  meetings. 

3.  Lectures  and  demonstrations. 

4.  Little  mothers'  leagues. 

5.  Weighing  and  measuring  babies. 

6.  Infant  welfare  stations. 


CHILD    HYGIENE  497 

A  public  health  nurse  is  the  field  agent  in  all  phases  of  infant 
welfare  work.  She  reaches  individual  mothers,  and  she  also 
seeks  to  secure  the  co-operation  of  those  women  who  are  recog- 
nized as  advisers  of  others  and  as  molders  of  public  opinion. 

After  a  nurse  becomes  acquainted  with  the  mothers,  she  will 
arrange  that  they  meet  in  small  groups  for  the  talks  and  demon- 
strations which  she  will  give  to  them,  and  later  she  will  arrange 
lectures  and  exhibits  to  which  the  public  will  be  invited.  The 
New  York  State  Department  of  Health  issues  pamphlets  on 
various  phases  of  the  care  of  infants. 

A  nurse  will  find  that  httle  mothers'  leagues  are  valuable, 
especially  in  sections  where  older  girls  have  to  care  for  their  young 
brothers  and  sisters.  A  league  is  organized  with  a  chairman, 
secretary,  and  treasurer,  and  a  series  of  twelve  lectures  and 
demonstrations  are  given.  The  program  of  a  session  consists  of 
reports  and  discussions  of  the  management  of  actual  cases. 
Each  lesson  consists  of  a  ten-minute  talk  by  the  nurse,  and  a 
twenty-minute  demonstration  of  some  phase  of  the  care  of  in- 
fants. Either  a  large  doll  or  an  actual  baby  is  used  as  the  sub- 
ject for  the  demonstration.  The  subjects  of  the  twelve  lessons 
are  as  follows: 

1.  Growth  and  development;  measurements  and  weights; 

the  special  senses. 

2.  Teeth — their  development  and  care. 

3.  Water  internally  and  externally — bathing;  cleaning  the 

eyes,  ears,  and  nose. 

4.  Fresh  air — its  value  in  the  home.     Outings. 

5.  Sleep  and  rest.     Making  beds. 

6.  Clothing  and  cleanliness.     Effects  of  too  much  clothing. 

7.  First  care  of  the  sick  baby. 

8.  Milk — mother's  and  cow's.     Modification  of  milk. 

9.  Artificial  feeding.     Substitutes  for  mother's  milk.    Feed- 

ing at  various  ages. 

10.  Care  of  milk  and  containers. 

11.  Home  pasteurization  of  milk;  preparation  of  milk  foods. 

12.  Preparation  of  cereal  waters  and  meat  juices. 

Members  of  little  mothers'  leagues  not  only  prepare  them- 
selves to  care  for  babies,  but  they  teach  their  parents  and 
neighbors,  and  advertise  the  work  of  the  pubhc  health  nurse. 

Organizing  and  conducting  baby  weeks,  baby  contests,  and 
baby  exhibits  are  also  activities  of  a  public  health  nurse.  One 
of  the  principal  values  of  these  activities  is  to  create  an  oppor- 
tunity to  weigh  and  measure  the  babies  of  a  community  and 
to  reach  those  who  are  below  standard.  The  standard  table 
of  heights  and  weights  is  as  follows: 
32 


498  THE   HEALTH    OFFICER 


Height, 

Weight, 

Age 

inches. 

pounds. 

At  birlh 

20 

Th 

3  months 

23 

13 

6  months 

26 

17 

9  months 

28 

20 

12  months 

29 

21 

15  months 

30 

22 

18  months 

31 

24 

21  months 

32 

25 

24  months .  . 

33 

27 

30  months 

35 

29 

36  months 

37 

32 

42  months 

38 

33 

48  months 

39 

35 

Infant  Welfare  Station. — If  a  community  has  10,000  or  more 
inhabitants,  it  can  prolTtably  concentrate  its  infant  welfare  work 
in  a  station  \vhich  is  supplied  with  a  complete  outfit  for  carry- 
ing on  all  phases  of  the  work.  A  nurse  and  ph}'sician  are  in 
attendance  at  regular  hours.  Babies  are  brought  to  the  station 
to  be  weighed  and  measured  at  regular  periods.  Advice  is  given 
to  parents,  and  milk  of  a  high  grade  is  sold  at  cost.  Mothers' 
meetings  are  held,  instruction  and  demonstrations  are  given, 
and  pamphlets  are  distributed.  Cases  of  sickness  are  treated; 
bu'.  the  principal  object  of  an  infant  welfare  station  is  to  keep 
babies  well.  To  have  one  of  its  registered  babies  sick  is  a  dis- 
credit to  an  infant  welfare  station. 

Preschool  Ages  of  Children. — A  public  health-  nurse  will  dis- 
cover many  defects  and  deformities  among  children  between 
the  ages  of  two  to  seven  years,  and  will  try  to  secure  their  cor- 
rection; but  it  has  not  been  found  necessary  or  practical  to  do 
intensive  preventive  work  among  them.  Children  in  the  pre- 
school age  are  reached  through  the  activities  of  infant  welfare 
work  and  of  medical  inspection  of  school  children. 

Medical  Inspection  of  School  Children. — The  examination  of 
recruits  for  the  American  Army  shows  that  one-quarter  of  all 
men  of  draft  age  have  serious  physical  defects  which  disqualify 
them  for  service.  Over  half  of  these  defects  could  have  been 
remedied  completely,  and  half  of  the  remainder  lessened,  if  the 
men  had  been  examined  and  treated  during  their  school  days. 
The  medical  examination  of  school  children  and  the  treatment 
of  their  defects  are  important  activities  for  every  department  of 
health.  The  examinations  and  corrections  in  some  states  are 
also  done  by  departments  of  education.  Defects  among  school 
children  of  country  districts  are  as  common  as  they  are  in  cities. 
Every  health  officer  is  expected  to  know  the  scope  of  the  work, 
and  to  promote  the  discovery  and  correction  of  defects  among 
the  children  in  his  jurisdiction. 


CHILD    HYGIENE  499 

The  minimum  staff  required  for  medical  inspection  consists 
of  a  public  health  nurse  and  a  physician,  both  of  whom  have 
been  legally  authorized  to  make  the  examinations.  A  full-time 
nurse  can  look  after  1000  or  2000  pupils. 

The  inspection  of  school  children  is  conducted  according  to 
two  methods : 

1.  A  thorough  examination  of  every  pupil  made  by  a  phy- 
sician every  year  or  two. 

2.  An  examination  by  a  physician  of  children  whom  the 
nurse  suspects  of  having  defects.  The  system  to  be  followed 
will  depend  largely  on  the  circumstances  in  the  particular 
school.  Either  method  will  produce  satisfactory  results  pro- 
vided both  the  nurse  and  the  physician  are  competent  and 
conscientious. 

Special  examinations  are  also  made  by  a  physician  or  nurse 
whenever  they  are  needed  in  order  to  discover  contagious  dis- 
eases or  special  defects  or  conditions.  A  nurse  is  as  competent 
as  a  physician  in  discovering  head  lice,  skin  diseases,  and  sore 
throats.  Nurses  make  daily  inspections  of  pupils  in  the  schools 
of  New  York  City. 

When  a  school  physician  examines  a  pupil,  he  will  make  note 
of  the  following  conditions : 

1.  Sight. 

2.  Hearing. 

3.  Throat  and  nose  abnormalities,  particularly  tonsils  and 

adenoids. 

4.  The  hair,  for  lice. 

5.  The  skin,  for  eruptions. 

6.  Hands  and  feet,  for  orthopedic  defects. 

7.  Heart. 

8.  Lungs. 

9.  General  nutrition. 

10.  Height  and  weight. 

11.  Special  conditions,  such  as  posture,  mental  attitude,  and 

cleanness  of  the  body. 

The  following  table,  based  on  the  examination  of  2,000,000 
children,  shows  the  percentage  of  children  who  showed  various 
defects : 

Teeth,  60  per  cent. 

Vision,  25 

Adenoids  and  enlarged  tonsils,  30        " 

Malnutrition,  25        " 

Orthopedic  defects,  5        " 

Tuberculosis,  5        " 

Heart  weakness,  2        " 


500  THE   HEALTH   OFFICER 

An  examiner  who  finds  few  or  no  defects  is  either  incom- 
petent or  careless.  Defects  which  are  evident  to  the  nurse 
and  the  teachers  are  common  in  every  school  room.  About  75 
per  cent,  of  all  school  children  ha\-e  ph}-sical  defects  that  re- 
quire treatment. 

Correction  of  Defects. — When  a  defect  is  found,  the  ne.xt 
step  is  to  inlomi  the  parents  or  guardian  of  the  child,  and  to 
advise  that  the  defect  be  corrected.  A  weakness  in  the  present 
system  of  the  medical  examination  of  school  children  is  that  no 
one  is  authorized  to  compel  the  parents  or  children  to  have  the 
corrections  made.  Experience  has  shown  that  when  the  parents 
are  merely  notified  of  the  defects,  only  about  10  per  cent,  of  the 
cases  are  corrected.  Two  measures  are  necessary  to  secure  the 
correction  of  the  defects:  1,  a  system  of  visiting  and  instructing 
the  parents  by  a  public  health  nurse;  and  2,  school  clinics,  dental 
clinics,  hospital  facilities,  and  other  provision  for  correcting  the 
defects  either  free  or  at  a  minimum  cost.  This  system  secures 
the  correction  of  over  80  per  cent,  of  the  defects  of  school  chil- 
dren in  New  York  City. 

An  important  result  of  the  medical  inspection  of  school  chil- 
dren is  the  discover}-  of  unsuspected  defects  of  sight  or  hearing 
which  are  the  cause  of  mental  deficiency,  disobedience,  bad 
behavior,  truancy,  and  other  manifestations  of  mental  abnor- 
malities. The  correction  of  these  cases  alone  would  justify  the 
entire  system  of  medical  inspection  (page  316). 

There  is  no  standard  method  of  making  medical  inspec- 
tions and  correcting  the  defects  that  are  found.  A  complete 
system  of  inspection  without  the  correction  of  defects  is  un- 
satisfactory, and  a  waste  of  time  and  money.  A  conscientious 
nurse  and  physician  can  readih-  find  the  ways  and  means  for 
correcting  the  physical  defects  of  the  school  children  of  their 
community. 

Inspection  of  School  Buildings. — The  inspection  of  school 
buildings,  or  the  environment  of  the  school  child,  is  closely 
related  to  the  work  of  medical  inspection.  A  health  officer 
inspecting  a  school  house  will  take  note  of  the  following 
points: 

1.  The  state  of  repair  of  the  building. 

2.  The  arrangement  of  the  rooms  and  hallways. 

3.  Cleanliness. 

4.  Water-supply. 

5.  Facilities  for  drinking. 

6.  Facilities  for  washing  the  hands  and  face. 

7.  Toilets  and  sewage  disposal. 

8.  Heating. 


CHILD    HYGIENE  501 

9.  Ventilation. 

10.  Lighting. 

11.  Blackboards. 

12.  Desks  and  seats,  and  their  adaptation  to  the  individual 

pupils. 

13.  Provision  for  hanging  the  outer  garments. 

14.  Unsanitary  conditions  adjoining  the  school  grounds. 


CHAPTER  XLIV 

LIFE  EXTENSION 

Adult  Death-rates. — The  work  of  departments  of  health  is 
essentially  the  prevention  of  disease.  There  has  been  a  gradual 
extension  of  the  scope  of  health  ofticer  activities  corresponding 
to  the  advance  in  scientific  knowledge  and  its  extension  among  the 
people.  These  activities  have  developed  in  about  the  following 
chronologic  order:  1,  the  control  of  contagious  diseases;  2,  gen- 
eral sanitation;  3,  pure  water-supplies;  4,  municipal  sewage  dis- 
posal; 5,  milk  control;  6,  food  inspection;  7,  industrial  hygiene, 
including  factory  inspection  and  the  employment  of  women  and 
children;  8,  child  hygiene;  and  9,  the  medical  inspection  of  school 
children.  These  activities  have  greatly  reduced  the  rates  for 
death  and  sickness.  The  reduction  has  not  been  uniform  for 
all  age  periods,  but  has  been  confined  to  those  in  the  earlier 
years  of  fife.  It  has  been  the  most  marked  among  infants  and 
children  when  persons  are  at  the  most  tender  and  impression- 
able ages  of  their  lives.  The  reduction  has  been  less  marked  in 
the  first  half  of  adult  life.  There  has  been  no  reduction  in  the 
death-rate  during  the  second  half  of  adult  life;  but,  on  the 
contrary,  there  has  been  an  increase  in  the  proportion  of  deaths 
among  persons  between  the  ages  of  forty  and  sixty-five.  The 
average  age  of  persons  who  are  over  forty  years  old  at  the  time 
of  death  is  now  less  than  it  was  one  hundred  years  ago.  A  per- 
son who  passes  the  age  of  forty  may  now  expect  to  live  fewer 
years  than  one  w^ho  lived  in  the  days  before  public  health  work 
was  organized.  Life  extension,  or  the  prolongation  of  the  years 
of  usefulness  and  efficiency  of  adult  persons,  is  a  coming  develop- 
ment in  public  health  work. 

A  reason  that  is  sometimes  given  for  the  increased  death- 
rate  among  adults  is  that  the  work  of  child  h}'giene  has  pro- 
longed the  lives  of  numerous  weaklings  who  are  unable  to  stand 
the  ordinary  strains  of  an  active  life.  While  a  few  grown-up 
persons  may  die  as  a  result  of  weaknesses  carried  over  from  child- 
hood, the  net  result  of  child  hygiene  is  to  increase  the  strength 
and  vigor  of  most  persons  who  reach  adult  fife. 

Degenerative  Diseases. — The  principal  cause  of  the  increas- 
ing death-rate  among  adults  is  the  prevalence  of  diseases  which 
begin  to  show  their  effects  after  the  middle  period  of  adult  life. 
502 


LIFE    EXTENSION  503 

These  are  classed  as  degenerative  diseases,  and  consist  in  the 
replacement  of  the  active  cells  with  fatty  or  fibrous  tissue. 

Fatly  Degeneration. — An  excessive  accumulation  of  fat  is 
often  associated  with  fatty  degeneration  of  the  voluntary  mus- 
cles. A  similar  condition  may  also  involve  the  heart,  the  liver, 
and  other  vital  organs,  and  be  the  direct  cause  of  death.  The 
condition  is  largely  a  nutritional  disturbance,  and  is  due  to  at 
least  three  causes: 

1.  The  retention  of  an  excessive  amount  of  food  material  in 
the  body. 

2.  A  deficiency  of  oxygen  with  which  to  oxidize  the  food 
material. 

3.  The  accumulation  of  poisonous  waste  products  which  are 
largely  those  of  suboxidation. 

Fatty  degeneration  is  not  strictly  a  disease  of  declining 
years;  but  it  frequently  develops  during  early  adult  life  owing 
to  the  lack  of  exercise  and  to  overeating  which  are  often 
associated  with  that  period.  Start  a  fifteen-year-old  boy  in 
a  business  ofl&ce,  keep  him  there  day  after  day  for  years,  feed 
him  with  great  quantities  of  rich  food,  and  allow  him  no  exer- 
cise or  recreation,  and  he  will  develop  an  incurable  fatty  degen- 
eration by  the  time  he  is  twenty-five  years  old. 

Fibrosis. — The  development  of  fibrous  tissue  throughout  the 
body  is  a  natural  process  during  advancing  years.  It  is  illus- 
trated by  the  toughness  of  meat  of  old  animals,  and  by  the  in- 
crease of  lime  salts  in  the  bones  of  old  persons.  It  may  involve 
all  parts  of  the  body,  but  its  evil  results  are  especially  evident 
when  the  process  affects  the  vital  organs,  particularly  the  arte- 
ries, heart,  kidneys,  liver,  and  brain.  The  signs  and  symptoms 
of  the  fibrosis  are  those  associated  with  the  following  conditions : 

1.  Hardness  and  inelasticity  of  the  arteries. 

2.  High  blood-pressure. 

3.  Heart  defects. 

4.  Kidney  disturbances, 

5.  Intestinal  and  liver  troubles. 

6.  Vague  aches  and  pains,  called  rheumatic,  neuralgic,  gouty, 

and  neuritic. 

7.  Gross  changes  in  the  joints. 

8.  Mental  derangements. 

9.  Apoplexy. 

Premature  Old  Age. — The  sjnmptoms  associated  with  fatty 
degeneration  and  fibrosis  constitute  the  signs  of  old  age.  Phys- 
ical degeneration  after  full  maturity  is  a  natural  condition  for 
man  and  for  all  other  living  beings.  The  signs  of  old  age  are 
normal  for  a  person  eighty  years  of  age;  but  they  are  abnormal 


504  THE   HEALTH    OFFICER 

for  one  between  forty  and  sixty.  The  increased  death-rate 
among  adults  over  forty  years  of  age  is  due  principally  to  condi- 
tions which  are  normally  associated  with  old  age.  The  deaths 
of  persons  dying  from  this  class  of  causes  are  usually  ascribed  to 
heart  failure,  or  kidney  disease,  or  apoplexy,  or  sudden  death 
without  definite  cause. 

The  causes  of  premature  old  age  are  complex  and  operate 
insidiously.  They  are  associated  with  a  high  state  of  civiliza- 
tion, and  may  be  classed  as  follows: 

1.  High  living. 

2.  Overindulgence  in  alcohol  and  tobacco. 

3.  S}philis. 

4.  A  sedentary  mode  of  life  when  personal  hygiene  is  not 

observed. 

5.  The  stresses,  strains,  and  worries  of  modern  life. 

6.  Intense  application  to  business. 

The  evidence  that  these  are  the  efficient  causes  of  the  degen- 
erations are : 

1.  The  improvement  that  follows  their  correction. 

2.  The  rareness  of  the  condition  in  those  who  are  not  under 
the  influence  of  the  causes. 

Prevention  of  Degenerative  Diseases. — Premature  old  age 
is  preventable,  and  its  causes  may  be  controlled.  The  general 
principles  of  the  prevention  of  degenerative  processes  may  be 
summarized  under  three  headings:  1,  a  simple  life;  2,  exercise; 
and  3,  recreation. 

A  physical  element  which  is  common  to  many  causes  of  de- 
generation is  suboxidation.  Oxidation  in  the  body  may  be  con- 
trolled by  regulating  either  the  amount  of  fuel  food  or  the  supply 
of  oxygen.  A  simple  mode  of  life  automatically  regulates  the 
intake  of  food,  for  it  involves  the  habit  of  eating  simple  meals 
of  a  few  dishes  simply  cooked ;  and  also  the  avoidance  of  alcoholic 
drinks  and  of  elaborate  dinners,  particularly  those  rich  in  pro- 
tein. A  simple  mode  of  life  is  also  an  antidote  for  nearly  every 
cause  of  physical  degeneration. 

The  only  practical  method  of  controlling  oxidation  is  by 
means  of  exercise.  It  is  a  life-saving  act  to  choose  a  mode  of 
life  in  which  some  part  of  the  daily  routine  requires  muscular 
exercise. 

The  mental  antidote  to  the  causes  of  premature  old  age  is 
recreation.  It  is  a  slow^  form  of  suicide  for  a  person  to  have  no 
other  interest  in  life  than  that  in  a  business  or  profession.  Both 
the  mind  and  the  body  require  daily  relief  from  the  continuous 
routine  of  a  business  or  a  profession.  An  avocation  or  hobby, 
as  well  as  a  vocation,  is  indispensable  to  health  and  happiness. 


LIFE    EXTENSION  505 

Four  difficulties  which  stancf  in  the  way  of  preventing  de- 
generative processes  are: 

1.  The  American  ideas  of  personal  independence  and  indi- 

vidual freedom  of  action. 

2.  Artificial  standards  of  success  and  of  living. 

3.  The  condition  often  affects  the  leaders  in  business  and 

professional  life  who  barter  health  for  success. 

4.  The  condition  does  not  endanger  others. 

Duty  of  the  Health  Officer. — A  health  officer  has  no  direct 
power  of  control  over  adults  who  are  threatened  with  degen- 
erative processes,  but  he  can  assist  in  the  work  by  educational 
measures.  The  army  authorities  have  demonstrated  the  prac- 
ticability of  direct  measures  for  promoting  the  physical  vigor  of 
adults.  The  more  progressive  departments  of  health  are  in- 
stituting campaigns  of  education  with  the  expectation  of  develop- 
ing public  measures  for  the  control  of  degenerative  diseases  along 
the  lines  that  have  been  adopted  in  the  army.  The  treatment 
and  prevention  of  the  diseases  of  adult  life  is  becoming  an  im- 
portant specialty  in  medicine. 

Periodic  Physical  Examinations. — A  measure  of  great  im- 
portance in  the  prevention  of  degenerative  diseases  of  adults 
is  the  periodic  medical  examination  of  each  individual.  Life 
insurance  workers  recognize  its  value,  and  some  of  the  more 
progressive  insurance  companies  are  developing  a  system  of 
regular  examinations  for  their  insured.  The  extension  of  a 
similar  system  to  all  persons  at  public  expense  is  a  probable 
development  of  future  public  health  work. 

Special  Diseases  of  Adults. — Special  causes  of  disability  and 
death  in  adults  are  focal  infections,  cancer,  and  accidents. 

Focal  infections  around  the  roots  of  the  teeth  are  frequent  in 
adults,  and  are  often  the  unsuspected  causes  of  sickness  and 
death  (page  158).  A  health  officer  can  do  much  to  combat  the 
conditions  by  educational  measures. 

Cancer  is  one  of  the  leading  causes  of  death  among  adults. 
Millions  of  dollars  have  been  given  for  endowments  for  cancer 
research,  and  numerous  skilled  investigators  are  working  to 
solve  the  problem  of  its  cause  and  prevention.  The  means  by 
which  a  health  officer  can  assist  jn  the  work  are : 

1.  Promoting  the  early  diagnosis  and  treatment  of  cases. 

2.  Collecting  data  of  cases  for  research  workers. 

3.  Educating  the  public  regarding  the  curability  of  cancer  in 
its  early  stages. 

One  result  of  the  hurry  and  bustle  of  modern  American  life 
is  the  great  number  of  accidents  that  are  clearly  due  to  prevent- 
able causes.     Over  9000  deaths  were  due  to  accident  in  New  York 


506  THE   HEALTH   OFFICER 

State  in  1917,  and  over  1000  were  caused  by  automobiles.  A 
health  ofiicer  can  assist  in  the  prevention  of  accidents  by  the 
following  means: 

1.  Calling  the  attention  of  the  people  to  the  record  of  deaths 
and  disabilities  from  accidents. 

2.  Promoting  the  enactment  of  laws  and  the  appointment  of 
policemen  and  inspectors  for  the  purpose  of  preventing  special 
fonns  of  accident. 

Public  Medicine. — A  great  hindrance  to  public  health  work 
is  the  lack  of  adequate  medical  attendance  upon  those  of  small 
financial  means.  Medical  service  in  America  is  a  matter  of 
private  contract  between  physician  and  patient.  It  is  usually 
the  custom  of  prosperous  physicians  to  refuse  to  attend  those 
who  cannot  pay  a  fee.  The  result  is  that  about  one-quarter  of 
the  people  receive  Httle  or  no  medical  attendance  except  in 
charitable  institutions,  and  another  quarter  call  a  physician  only 
in  emergencies.  Public  health  demands  that  every  person  shall 
receive  competent  medical  attention.  Many  industrial  corpora- 
tions consider  it  good  business  to  provide  medical  attention  for 
their  unskilled  laborers.  It  w'ould  be  of  equal  benefit  to  the 
public  to  pro\'ide  medical  attention  for  those  who  otherwise 
would  not  receive  the  benefits  of  curative  and  preventive  medi- 
cine. The  problem  will  probably  be  solved  by  departments  of 
health.  Health  officers  have  already  taken  up  the  work  of  child 
hygiene  and  the  correction  of  the  defects  of  school  children.  It 
is  a  natural  extension  of  their  work  to  extend  it  to  the  prevention 
and  correction  of  physical  defects  of  adults. 


INDEX 


Abortion,  contagious,  354 
Accidents,  479 

automobile,  505 
Acid,  lactic,  349 

Activities  of  health  department,  22,  30, 
69 

of  public  health  nurse,  116 
Acute  respiratory  diseases,  236 
Adenoids,  169 
Adult  life  diseases,  502 
Adulteration,  345,  371 
Aerobic  bacteria,  134,  422 
Age  groups,  106 

old,  503 
Agglutination,  145 

group,  147 
Air  and  disease,  174,  472 

space,  475 
Amboceptor,  148 
Ammonia,  454 
Anaerobic  bacteria,  134,  422 
Analysis,  air,  473 

water,  458 
Anaphylaxis,  142 
Animal  inoculation,  138 
Animals,  diseased,  90,  277,  304,  309, 341, 

352,  363,  373,  416  . 
Annual  report,  67 
Anopheles,  302,  335 
Anthrax,  310 
Antibodies,  144 
Antigen,  148 
Antimony,  478 
Antitoxin,  144,  218,  220,  276 
Area,  registration,  100 
Arsenic,  478 
Artificial  feeding,  493 
Automobile  accidents,  505 

Babcock  test,  345 

Bacilli,  colon,  254,  356,  377,  446,  456 


Bacteria,  aerobic,  134,  422 

anaerobic,  134,  422 

in  air,  170,  174,  472 

in  milk,  348 
Bacteriology,  128 
Balanced  diet,  389 
Barber  shops,  417 
Bed,  contact,  442 
Bedbugs,  339 
Beriberi,  396 
Bill  of  fare,  397 
Binet  test,  324 
Births,  101 
Blindness,  306 

Board  of  health,  18,  34,  76,  81,  421 
Bodies,  Negri,  278 
Botulismus,  374 
Brill's  disease,  304 

Caisson  disease,  479 

Calorie,  387,  389 

Camp  sanitation,  482 

Cancer,  505 

Canned  food,  376 

Carbohydrates,  385,  423,  428 

Care,  prenatal,  490 

Carriers,  176,  221,  244,  257,  271 

Catechism  on  colds,  250 

Certificates,  death,  104 

Certified  milk,  361 

Cesspool,  427,  438 

Chancroid,  280 

Chicken-pox,  199,  203 

Child  hygiene,  488 

Children,  school,  medical  inspection  of, 

498 
Chlorin,  455 
Chlorination,  446,  461 
Cholera,  265 
Cistern,  450 
Cleanliness,  191 

507 


508 


INDEX 


Climate,  175,  468 

Code,  sanitan-,  42,  81,432 

Cold  storage,  375 

Colds,  153,  243.  250 

Colon  bacilli,  254,  356,  377,  446,  456 

Communicable  diseases,  110,  160,  487 

and  health  officer,  183 
Complaint,  summer,  265 
Complement,  148 

fixation,  149 
Conjunctivitis,  follicular,  307 
Contact  bed,  442 

infection,  170 
Contacts,  178,  189 
Contagious  abortion,  354 

diseases,  168 
Control  of  epidemics,  181 
Cough,  whooping-,  241 
Council,  public  health,  19 
Court  action,  78,  420 
Cow,  examination  of,  363 
Co\\pox,  206,  354 
Culex,  336 
Cultures,  132,  213 

enrichment  of,  136,  257 
Cups,  drinking,  417 

Death  certificates,  104 

rate,  57,  105 
Decay,  350,  412.  422 
Decomposition,  372,  423 
Defects,  mental,  313 
Degeneration,  fatty,  503 
Department  of  health,  state,  17,  36 
Diarrhea,  254,  494 
Diet,  balanced,  389 
Digestion,  parenteral,  141 
Diphtheria,  144,  212 
Disease  and  air,  174,  472 

and  environment,  407 

and  insects,  301 

and  milk,  173,  225,  351 

Brill's,  304 

caisson,  479 

hookworm,  308 
Diseased  animals,  90,  277,  304,  309,  341 

352,  363,  373,  416 
Diseases,  acute  respiratory,  236 

adult  life,  502 

communicable,  160,  183,  487 


Diseases,  contagious,  168 

eye,  306 

management,  183 

mental,  and  drugs,  317 

occupational,  478 

reportable,  160 

respiratory,  495 
acute,  236 

venereal,  280 
Dishes,  washing,  382 
Disinfection,  191 
Disposal  of  excretions,  422,  434,  487 

of  sewage,  434 
Disturbances,  nutritional,  494 
Dogs,  277 
Drafts,  175 

Drainage,  kitchen,  427 
Drinking  cups,  417 
Droplet  infection,  170 
Drugs  and  mental  diseases,  317 
Dust,  174,  246,  467,  471 
Duties  of  physician,  28,  50,  55,  179 
Dysentery,  264 

Education,  public  health,  28,  47,  119, 

121,234,  249,288,433 
Ehrlich's  side-chain  theory,  151 
Engineering,  sanitary,  399,  447 
Enrichment  of  cultures,  136 
Environment  and  disease,  407 
Epidemics,  control  of,  181 
Epidemiology,  168 
Examination  of  air,  473 

of  cow,  363 

of  water,  452 

periodic  physical,  505 
Excretions,  190,  232,  259 

disposal  of,  190,  425,  487 
Exhibits,  126 
Eye  diseases,  306 
Eyelids,  granulated,  307 

Factory  hygiene,  480 
Fatigue,  153 
Fats,  385,  423 
Fatty  degeneration,  503 
Feeble -mindedness,  324 
Feeding,  artificial,  493 
Fermentation,  350,  372,  376 
Fever,  scarlet,  226,  229 


INDEX 


509 


Fever,  spotted,  268,  303 

Texas,  340 

typhoid,  147,  254,  379 

typhus,  303 

yellow,  302 
Fibrosis,  503 

Filters,  129,  442,  443,  461 
Filtration,  424,  438,  443,  461 
Finances,  40 
Fleas,  304,  340 
Flies,  255,  261,  327,  426 
Flipper,  376 
Fluorescin  test,  452 
Fly  traps,  333 
Focal  infections,  158,  505 
Follicular  conjunctivitis,  307 
Fomites,  172 
Food,  153,  384 

canned,  376 

handling,  378,  380 

infection,  262,  380 

inspection,  380 

poisoning,  263,  373 

preserving,  375 

regulative,  394 

sanitation,  371 

score  card,  381 

stores,  380,  415 

values,  384 
Foreign  protein,  148 
Fumigation,  342 

Garbage,  428 
German  measles,  199 
Glanders,  310 
Goat's  milk,  493 
Gonococci,  281,  306 
Gonorrhea,  281 
Grading  milk,  360 
Granulated  lids,  307 
Ground  water,  451 
Group  agglutination,  147 
Groups,  age,  106 

Handbills,  125 
Hand  infection,  171 
Handling  of  food,  378,  380 
Hard  water,  462 

Health,  board  of,  18,  34,  76,  81,  421 
department,  activities  of,  22,  30,  69 


Health  department,  state,  17,  36 
officer,  25 
activities,  22,  30 

and  communicable  disease,  183,  228 
appointment,  40 
board  of  health,  35 
education  of,  26,  40 
outfits,  166 

qualifications,  25,  32,  62,  192 
salary,  49 

source  of  power,  20 
staff,  23 
public,  council,  19 
education,  28, 47,  119,  121,  234,  249, 

288,  433 
nurse,  24,  112,  299,  489 
activities,  116 
methods  of  work,  115 
qualifications,  114 
Heat,  191 

Heating  houses,  473 
Heredity,  314 

Hibernation  of  oysters,  378 
Hookworm  disease,  308 
Hospitals,  187 
Household  wastes,  422,  486 
Houses,  heating,  473 

milk,  366 
Housing,  96,  402,  417 
Humidity,  466,  470,  474 
Hygiene,  child,  488 
factory,  480 
industrial,  403,  477 
rural,  56,  61,  488 
Hygrometer,  466 

Imhoff  tank,  441 
Immunity,  140,  154,  217,  220,  293 
Impurities  in  water,  449 
Industrial  hygiene,  403,  477 
Infant  mortality,  488,  492 

welfare,  492 
Infantile  paralysis,  271 
Infection,  contact,  170 

droplet,  170 

focal,  158,  505 

food,  262,  378 

hand,  171 

water-borne,  172 
Influenza,  243 


510 


INDEX 


Injunction,  80,  420 
Inoculation,  animal,  138,  293 
Insanity,  317,  320 
Insects  and  disease,  174,  301 
Inspection  of  food,  380 

of  kitchens,  485 

of  meat,  377 

of  school  children,  medical,  498 

of  water,  452 
Intubation,  217 

Investigations,  73,  178,  261,  418,  451 
Iron  in  water,  463 
Irrigation,  subsurface,  440 
Isolation,  53,  187,  189,  216,  232 

Kitchen  drainage,  427 
inspection,  485 

Laboratory, 159,  405 
Lactic  acid,  349 
Law,  19,  39 

jNIendel's,  314 
Lay  societies,  29 
Lead-poisoning,  478 
Leagues,  little  mothers',  497 
Lectures,  125 
Legal  duties,  43 

procedures,  73,  193,  419 
Leprosy,  312 
Lice,  304,  338 
Licenses,  432 
Life  extension,  502 
Little  mothers'  leagues,  497 
Lysin,  148 

Maggots,  329 
Malaria,  301,  335 
Mallein  test,  310 
Manure,  95,  364 
^Marriages,  101 
Masks,  249 
Measles,  196 

German,  199 
Meat  inspection,  377 
Medical  inspection  of  school  children, 

498 
Medicine,  public,  506 
Mendel's  law,  314 
Meningitis,  267 
Mental  defects,  313 


Mental  diseases  and  drugs,  317 
Mercury,  478 
Metallic  poisons,  478 
Midwives,  490 
Milk,  91,  344 

and  disease,  173,  225,  351 

certified,  361 

goat's,  493 

grading,  360 

house,  366 

pails,  366 

permits,  362 

score  cards,  358,  362 
Molds,  139 
Morbidity  rates,  110 
jMortality,  infant,  488,  492 
]\Iosquito,  302,  334 
]\lothers'  leagues,  497 
Mouth,  154,  169 
Mumps,  201 

Negri  bodies,  278 

Newspapers,  124 

Nitrates,  454 

Nitrites,  454 

Nits,  338 

Noise,  416 

Nose,  169 

Notice,  75,  419 

Nuisances,  87,  406 

Nurse,  public  health,  24,  112,  299,  489 

acti\ities,  116 

methods  of  work,  115 

qualifications,  114 
Nutritional  disturbances,  494 

OccUTATiONAL  diseases,  478 

Odors,  96,  175,  413,  473 

Officer,  public  health.    See  Health  officer. 

Old  age,  503 

Ophthalmia  neonatorum,  306 

Opsonins,  150 

Orders,  77,  421 

Ordinances,  42,  85,  382,  432 

Oysters,  377 

hibernation  of,  378 

scoring,  378 

Pails,  milk,  366 
Paralysis,  274 
Paratyphoid,  263,  373 


INDEX 


511 


Parenteral  digestion,  141 
Pasteurization,  227,  354 
Periodic  physical  examination,  505 
Permits,  milk,  362 
Phagocytosis,  140 
Physical  examination,  periodic,  505 
Physician,  duties  of,  28,  50,  55,  179 
Pigs,  96,  309,  311 
Pinkeye,  306 
Pit,  Woodruff,  428 
Plague,  304,  340 
Pneumococci,  237 
Pneumonia,  237 
Poisoning,  food,  263,  373 
lead-,  478 
sausage,  374 
Poisons,  metallic,  478 
Police  power,  21 
Poliomyelitis,  271 
Pollution,  stream,  95,  414 
Population,  98 
Posters,  125 
Precipitin  test,  147 
Prenatal  care,  490 
Preserving  food,  375 
Privy,  429 

Procedures,  73,  86,  193,  418 
Protein,  384,  423 

foreign,  148 
Ptomains,  264 
Public  health  council,  19 

education,  28, 47,  119, 121, 234,  249, 

288,  433 
nurse,  24,  112,  299,  489 
activities,  116 
methods  of  work,  115 
qualifications,  114 
ofl&cer.     See  Health  officer. 
service,  United  States,  17 
medicine,  506 
Publicity,  119,  124 
Puncture,  spinal,  269,  273 
Purification,  water,  460 
Putrefaction,  350,  372,  422,  441 
Pyrethrum,  332 

Qualifications  of  public  health  nurse, 
114 
oflficer,  25,  32,  62,  192 
Quarantine,  187 


Rabies,  277 

Rates,  morbidity,  110 

Rats,  311,  341 

Records,  30,  44,  51,63,  295 

Registration  area,  100 

Regulative  foods,  394 

Reportable  diseases,  110,  160 

Reservoirs,  461 

Resistance,  152 

Respiratory  diseases,  495 

acute,  236 
Rickets,  495 
Rural  hygiene,  56,  61,  488 

Sand  filter,  443 

Sanitary  code,  42,  81,  382,  432 

engineering,  399 

survey,  69,  403 
Sanitation,  camp,  482 

food,  371 
Sausage  poisoning,  374 
Scarlet  fever,  226,  229 
Scavengers,  432 
Schick  test,  219 
Schools,  223,  231 

medical  inspection  of,  498 
Score  card,  food,  381 
milk,  358,  362 
United  States,  381 
Scoring  food  stores,  380 

oysters,  378 
Scurvy,  394,  495 
Sediment  test,  347 
Sensitization,  142,  148 
Septic  sore  throat,  225 
Serum,  141,  157,  240,  270,  274 
Service,  public  health.  United  States,  17 
Settling  tank,  437 
Sewage,  93 

disposal,  434 
Shed,  water-,  451 
Shops,  barber,  417 
Side-chain  theory,  Ehrlich's,  151 
Sludge,  441 
Smallpox,  200,  202 
Smoke,  416 
Societies,  lay,  29 
Sore  throat,  septic,  225 
Spinal  puncture,  269,  273 
Spitting,  472 


512 


INDEX 


Spotted  fever,  268,  303  _ 
Springer,  376 
Sprinkling  filter,  442 
Stables,  364 
Stagnant  water,  414 
Staining,  137 

State  department  of  health,  17,  36 
Statistics,  vital,  54,  97,  403 
Storage,  cold,  375 
Stores,  food,  380,  415 
Stream  pollution,  95,  414 
Streptococci,  226,  231,  236 
Subsurface  irrigation,  440 
Summar}-  abatement,  76,  420 
Summer  comjilaint,  265 
Supply,  water-,  449,  485 
Sur\'ey,  sanitary,  69,  403 
SuscepUbility,  144,  293 
Sweller,  376 
Syphilis,  283 

Taxk,  Imhoflf,  441 

settling,  437 
Tapeworm,  309 
Test,  Babcock,  345 

Binet,  324 

fluorescin,  452 

mallein,  310 

precipitin,  147 

Schick,  219 

sediment,  347 

virulence,  221 

Wassermann,  150 

Widal,  147,  256 
Tetanus,  276 
Texas  fever,  340 

Theorj',  Ehrlich's  side-chain,  151 
Throat,  septic  sore,  225 
Ticks,  340 
Tonsillitis,  225 
Tonsils,  158,  169 
Towels,  417 
Toxin,  144 

Toxin-antitoxin  immunity,  220 
Trachoma,  307 
Traps,  fly,  333 
Trichinosis,  311 
Tuberculin,  294,  353 
Tuberculosis,  54,  290,  376 


Tuberculosis,  bo\ane,  295,  352 
Typhoid  fever,  147,  254,  379 

vaccination,  258 
Typhus  fever,  303 

UxiTED  States  public  health  service,  17 
score  card,  381 

Vaccination,  54,  206 

typhoid,  258 
Vaccines,  156,  242 
Vaccinia,  206,  354 
Values,  food,  384 
Venereal  diseases,  280 
Ventilation,  465,  475 
Vermin,  93,  327 
Vincent's  angina,  223 
Virulence  test,  221 
Vital  statistics,  54,  97,  403 
Vitamins,  395 

Washing  dishes,  382 
Wassermann  test,  150 
Wastes,  household,  422,  486 
Water,  94,  449 

analyses,  458 

examination,  452 

filtration,  461 

ground,  451 

hardness,  462 

impurities  in,  449 

infection,  172,  449 

iron  in,  463 

purification,  460 

stagnant,  414 
^^'ater- borne  infection,  172,  449 
Water-shed,  451 
Water-supply,  449,  485 
Weather,  175,  468 
Welfare,  infant,  492 

work,  481 
Whooping-cough,  241 
Widal  reaction,  147,  256 
Woodruff  pit,  428 

x-Rav,  239,  297 

Yeast,  139 
Yellow  fever,  302 


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and  the  Allied  Sciences 


W.  B.  SAUNDERS   COMPANY 

WEST  WASHINGTON  SQUARE       PHILADELPHIA 
9,  HENRIETTA  STREET,  COVENT  GARDEN.  LONDON 

Garrison's 
History  of  Medicine 

History  of  Medicine.  With  Medical  Chronology,  Bibliographic 
Data,  and  Test  Questions.  By  Fielding  H.  Garrison,  M.  D.,  Prin- 
cipal Assistant  Librarian,  Surgeon-General's  Office,  Washington,  D.  C. 
Cloth,  ;^6.oo  net;  Half  Morocco,  $7.50  net. 

REPRINTED  IN  THREE  MONTHS— THE  BAEDEKER  OF  MEDICAL  HISTORY 

The  work  begins  with  ancient  and  primitive  medicine,  and  carries  you  in  a 
most  interesting  and  instructive  way  on  through  Egyptian  medicine,  Sumerian 
and  Oriental  medicine,  Greek  medicine,  the  Byzantine  period  ;  the  Mohammedan 
and  Jewish  periods,  the  Medieval  period,  the  period  of  the  Renaissance,  the  Re- 
vival of  learning  and  the  Reformation  ;  the  Seventeenth  Centurj'  (the  age  of  indi- 
vidual scientific  endeavor),  the  Eighteenth  Century  (the  age  of  theories  and 
systems),  the  Nineteenth  Century  (the  beginning  of  organized  advancement  of 
science),  the  Twentieth  Century  (the  beginning  of  organized  preventive  medicine). 
You  get  all  the  important  facts  in  medical  history  ;  a  biographic  dictiofia?y  of  the 
makers  of  medical  history,  arranged  alphabetically  ;  an  album  oi  medical  portraits  ; 
a  complete  medical  chronology  (data  on  diseases,  drugs,  operations,  etc. ) ;  a  brief 
survey  of  the  social  and  cultural  phases  of  each  period. 


S.nWPERS'    /!OOA'S    ON 


A  NEW  CLINICAL  PUBLICATION 

Medical  Clinics  of  Chicago 

Issued  serially,  one  octavo  of  200  pages,  illustrated,  eveiy  other 
month.  Sold  only  by  the  Clinic  Year  (July  to  May),  six  volumes. 
Cloth,  $12.00  net. 

EXCLUSIVELY  INTERNAL  MEDICINE 

These  bi-monthly  pul^hcations  are  devoted  exchisi\ely  to  Clinical  Intirnal 
Medicine-  in  all  its  departments— Diseases  of  Children,  Contagious  Diseases,  Neu- 
rology, Dermatology,  General  Constitutional  and  Functional  Disorders,  Fevers, 
A'-Ray  Therapy,  etc. ,  etc.  They  give  you  the  bedside  and  amphitheater  teachings 
of  such  leading  Chicago  internists  as  Mix,  Tivnen,  Tice,  Case,  Portis,  Weaver, 
Friedman,  Hamburger,  Pusey,  Williamson,  Edwards,  Abt,  Preble,  Goodkind, 
Hamill,  Strouse,  Brophy,  Zeisler,  representing  such  large  hospitals  as  Mercy, 
Cook  County,  St.  Luke's,  Michael  Reese,  and  Sarah  Morris  Memorial  for  Children, 
with  their  wealth  and  diversity  of  clinical  material.  These  clinics  are  stenograph- 
ically  reported  by  a  corps  of  competent  medical  stenographers,  and  thoroughly 
edited  by  the  clinical  teachers  therhselves. 

The  widest  variety  of  cases  is  included,  bringing  out  forcibly  every  feature  of 
histor)'-taking,  diagnosis,  treatment,  and  general  management.  The  cases  are 
illustrated  with  .r-ray  pictures,  photographs,  pulse-tracings,  and  temperature 
charts  ;  the  technic  of  all  laboratory  tests  is  given  in  detail,  and  every  aid  that 
can  serve  to  make  the  diagnosis  and  treatment  of  the  cases  thoroughly  clear  to 
the  general  practitioner  is  emphasized.  These  publications  are  clinical  in  the 
strictest  sense — they  are  an  exposition  of  diagnosis  and  treatment  as  actually  prac- 
ticed at  the  bedside  and  in  the  amphitheater. 


Goepp's  State  Board  Questions  Third  Edition 

State  Board  Questions  and  Answers.  By  R.  Max  Goepp,  M.  D., 
Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  Octavo  of  715 
pages.  Cloth,  $4.00  net  ;  Half  Morocco,  $5. 50  net. 

"  Nothing  has  been  printed  which  is  so  admirably  adapted  as  a  guide  and  self-quiz  for 
those  intending  to  take  State  Board  Examinations." — Pennsylvania  Medical  Journal. 


DIAGNOSIS  AND    TREATMENT 


Cabot's  Works  on  Dia£(nosis 

Differential  Diagnosis.  Presented  through  an  Analysis  of  Cases. 
By  Richard  C.  Cabot,  M.  D.,  Assistant  Professor  of  Ch'nical  Medi- 
cine, Harvard  Medical  School,  Boston.  Each  volume  an  octavo  of 
about  750  pages,  illustrated.  Per  volume  :  Cloth,  ^5.50  net. 

Dr.  Cabot's  work  takes  up  diagnosis  from  the  point  of  view  oi  ih^  presenting 
symptom — the  symptom  in  any  disease  which  holds  the  foreground  in  the  clinical 
picture  :  the  principal  complaint.  It  groups  diseases  under  these  symptoms,  and 
points  the  way  to  proper  reasoning  in  coming  to  a  correct  diagnosis.  It  works 
backward  from  each  leading  symptom  to  the  actual  organic  cause  of  the  symptom. 
This  the  author  does  by  means  of  case-teaching. 

The  symptom-groups  considered  in  Volume  I  [New  (3d)  Edition]  are :  Headache,  gen- 
eral abdominal  pain,  epigastric  pain,  right  hypochondriac  pain,  left  hypochondriac  pain,  right 
iliac  pain,  left  iliac  pain,  axillary  pain,  pain  in  arms,  pain  in  legs  and  feet,  fevers,  chills, 
coma,  convulsions,  weakness,  cough,  vomiting,  hematuria,  dyspnea,  jaundice,  and  nervous- 
ness— 21  symptoms  and  385  cases. 

Volume  II  (Just  Out)  :  Abdominal  and  other  tumors,  vertigo,  diarrhea,  dyspepsia, 
hematemesis,  enlarged  glands,  blood  in  stools,  swelling  of  face,  hemoptysis,  edema  of  legs, 
frequent  micturition  and  polyuria,  fainting,  hoarseness,  pallor,  swelling  of  arm,  delirium,  pal- 
pitation and  arhythmia,  tremor,  ascites  and  abdominal  enlargement — a  total  of  19  symptoms 
and  317  instructive  cases. 


Morrow's  Diagnostic  and 
Therapeutic  Technic 

Diagnostic  and  Therapeutic  Technic.  By  Albert  S.  Morrow, 
M.  D.,  Clinical  Professor  of  Surgery,  New  York  Polyclinic.  Octavo 
of  834  pages,  with  860  original  line  drawings.  Cloth,  ;$S.oo  net. 

NEW  (2d)  EDITION 

Dr.  Morrow's  new  work  is  decidedly  a  work  for  you — the  physician  engaged 
in  general  practice.  It  is  a  work  you  need  because  it  tells  you  just  how  to  perform 
those  procedures  required  of  you  every  day,  and  it  tells  you  and  shows  you  by 
clear,  new  line-drawings,  in  a  way  never  before  approached.  It  is  not  a  book  on 
drug  therapy  ;  it  deals  alone  with  physical  or  mechanical  diagnostic  and  thera- 
peutic measures.  The  information  it  gives  is  such  as  you  need  to  know  every 
day — transfusion  and  infusion,  hypodermic  medication,  Bier's  hyperemia,  explora- 
tory punctures,  aspirations,  anesthesia,  etc.  Then  follow  descriptions  of  those 
measures  employed  in  the  diagnosis  and  treatment  of  diseases  of  special  regions  or 
organs:  proctoclysis,  cystoscopy,  etc. 
JoumzJ  American  Medical  Association 

"The  procedures  described  are  those  which  practitioners  may  at  some  time  be  called 
on  to  perform.'' 


S.4 c.yi)£ji:s-  BOOKS  av 


Musser  and   Kelly  on 
Treatment 

A  Handbook  of  Practical  Treatment.  By  82  eminent  specialists. 
Edited  by  John  H.  Musser,  M.  D.,  and  A.  O.  J.  Kelly,  M.  U.,  Univer- 
sity of  Pennsylvania.  Three  octa\os  of  950  pages  each,  illustrated. 
Per  volume :  Cloth,  $6.00  net ;  Half  Morocco,  37-50  net.  Subscrip- 
tion. 

IN  THREE  VOLUMES 
A  PRACTICF  FOR  QUICK  REFERENCE  AND  DAILY  USE 

Every  chapter  in  this  work  was  written  by  a  speciaHst  of  unquestioned  authority. 
Not  only  is  drug  therapy  given  but  also  dietotherapy,  serumtherapy,  organo- 
therapy, rest-cure,  exercise  and  massage,  hydrotherapy,  climatology,  electro- 
therapy, .r-ray,  and  radial  activity  are  fully,  clearly,  and  definitely  discussed. 
Those  measures  partaking  of  a  surgical  nature  ha\e  been  presented  by  surgeons. 

The  Medical  Record 

"  The  most  modern  and  advanced  views  are  presented.  Itis  difficult  to  pick  out  any  one 
topic  that  deserves  special  commendation,  all  parts  fully  covering  their  particular  field,  and 
written  with  that  fulness  of  detail  demanded  by  the  every-day  needs  of  the  practitioner." 


Thomson's   Clinical   Medicine 

Clinical  Medicine.     By  William  Hanna  Thomson,  M.  D.,  LL.  D., 

formerly  Professor  of  the   Practice  of  Medicine  and  of  Diseases  of  the 

Nervous  System,  New  York   Universit}-  Medical  College.     Octavo  of 

675  pages.  Cloth,  $5.00  net ;   Half  Morocco,  ;^6.50  net. 

TWO  PRINTINGS  IN  FOUR  MONTHS 

This  new  work  represents  over  a  half  century  of  active  practice  and  teach- 
ing. It  deals  with  bedside  medicine — the  application  of  medical  knowledge  for 
the  relief  of  the  sick.  First  the  meaning  of  common  and  important  symptoms  is 
stated  definitely ;  then  follows  a  chapter  on  the  use  of  remedies  and  a  classifi- 
cation of  them  ;  next  the  section  on  infections,  and  last  a  section  on  diseases  of  par- 
ticular organs  and  tissues.  It  is  medical  knowledge  applied — from  cover  to  cover. 
An  important  chapter  is  that  on  the  mechanism  of  surface  chill  and  "catching 
cold,"  going  very  clearly  into  the  etiologic  factors,  and  outlining  the  treatment. 
The  chapter  on  remedies  takes  up  non-medicinal  and  medicinal  remedies  and 
vaccine  and se7um  therapy.  In  the  chapter  on  the  ductless  glands  the  subject  of 
internal  secretions  is  ver)'  clearly  presented,  giving  you  the  latest  advances.  The 
infectious  diseases  are  taken  up  in  Part  II,  while  Part  III  deals  with  diseases  of 
special  organs  or  tissues,  every  disease  being  fully  presented  from  the  clinical 
side.     Treatment,  naturally,  is  very  full. 


PRACTICE    OF  MEDICINE 


Ward's  Bedside  Hematology 

Bedside  Hematology.  By  Gordon  R.  Ward,  M.D.,  Fellow  of  the 
Royal  Society  of  Medicine,  London,  England.  Octavo  of  394  pages, 
illustrated.  Cloth,  ^3.50  net. 

INCLUDING  VACCINES  AND  SERUMS 

Dr.  Ward's  work  gives  you  the  exact  technic  for  obtaining  the  blood  for  ex- 
amination, the  making  of  smears,  the  blood-count,  finding  coagulation  time,  etc. 
Then  it  takes  up  each  disease,  giving  you  the  synonyms,  definition,  nature,  gen- 
eral pathology,  etiology,  bearings  of  age  and  sex,  the  onset,  symptomatology  (dis- 
cussing each  symptom  hi  detail),  course  of  the  disease,  clinical  varieties,  compli- 
cations, diagnosis,  and  treatment  (drug,  diet,  rest,  vaccines  and  serums,  etc.). 


Faught*s  Blood-Pressure 

Blood  "Pressure  from  the  Clinical  Standpoint.  By  Francis  A. 
Faught,  M.  D.,  formerly  Instructor  in  Medicine,  Medico-Chirurgical 
College  of  Philadelphia,     Octavo  of  475  pages,  illustrated. 

JUST  OUT— NEW  (2d)  EDITION 

Dr.  Faught' s  book  is  designed  for  practical  help  af  the  bedside.  Besides  the 
actual  technic  of  using  the  sphygmomanometer  in  diagnosing  disease,  Dr.  Faught 
has  included  a  brief  general  discussion  of  the  process  of  circulation.  The  practical 
application  of  sphygmomanometric  findings  within  recent  years  make  it  imperative 
for  every  medical  man  to  have  close  at  hand  an  up-to-date  work  on  this  subject. 


Smith's  What  to  Eat  and  Why 

What  to  Eat  and  Why.     By   G.    Carroll   Smith,  M.D.,  Boston. 

I2mo  of  377  pages.     Cloth,  $2:50  net. 

NEW  (2d)   EDITION 

With  this  book  you  no  longer  need  send  your  patients  to  a  specialist  to  be 
dieted — you  will  be  able  to  prescribe  the  suitable  diet  yourself  just  as  you  do 
other  forms  of  therapy.  Dr.  Smith  gives  the  "why"  of  each  statement  he 
makes.  It  is  this  knowing  why  which  gives  you  confidence  in  the  book,  which 
makes  you  feel  that  Dr.  Smith  knows. 

Pennsylvania  Medical  Journal 

"All  through  this  book  Dr.  Smith  has  added  to  his  dietetic  hints  a  great  many  valuable  ones 
of  a  general  nature,  which  will  appeal  to  the  general  practitioner." 


S.4l/^'I)£/^:S'    BOOA'S    OA' 


Kolmer*s  Specific  Therapy 


Infection,  Immunity,  and  Specific  Therapy.  By  John  A.  Kolmer, 
M.  D.,  Dr.  p.  H.,  In.structor  in  Experimental  Pathology,  University  of 
Pennsylvania.  Octavo  of  900  pages,  with  143  original  illustrations,  43 
in  colors,  drawn  by  Erwin  F.  Faber.  Cloth,  ^6.00  net ;  Half  Morocco, 
$7.50  net. 

ORIGINAL  ILLUSTRATIONS 

Dr.  Kolmer' s  book  gives  you  a  full  account  of  infection  and  immunity,  and 
/Ae  application  of  this  knowledge  in  the  specific  diagnosis,  prevention,  and  treat- 
ment of  disease.  The  section  de\oted  to  iiuinunologic  technic  gi\es  you  every  de- 
tail, from  the  care  of  the  centrifuge  and  making  a  simple  pipet  to  the  actual  pro- 
duction of  serums 'and  vaccines.  Under  specific  therapy  you  get  methods  of 
making  autogenous  vaccines  and  their  actual  nse  in  diagnosis  and  treatment.  The 
directions  for  injecting  vaccines,  serums,  salvarsan,  etc. — with  the  exact  dosage — 
are  here  given  so  clearly  that  you  will  be  able  to  use  these  means  of  treatment  in 
your  daily  practice.  You  also  get  full  directions  for  making  the  clinical  diagnostic 
reactions — the  various  tuberculin  tests,  luetin,  mallein,  and  similar  reactions,  all  illus- 
trated with  colored  plates.     The  final  section  is  devoted  to  laboratory  experimefits. 


Anders  &  Boston's  Medical  Diag^nosis 


A  Text-Book  of  Medical  Diagnosis.  By  James  M.  Anders,  M.  D., 
Ph.  D.,  LL.D.,  Professor  of  the  Theory  and  Practice  of  Medicine  and 
of  Clinical  Medicine,  and  L.  Napoleon  Boston,  M.  D.,  Professor  of 
Physical  Diagnosis,  Medico-Chirurgical  College,  Philadelphia.  Octavo 
of  1248  pages,  with  466  illustrations,  a  number  in  colors.  Cloth,  $6.00 
net;  Half  Morocco,  ^7.50  net. 

NEW  (2d)  EDITION 

This  new  edition  is  designed  expressly  for  the  general  practitioner.  The 

methods  given  are  practical  and  especially  adapted  for  quick  reference.  The 

diagnostic  methods  are  presented  in  a  forceful,  definite  way  by  men  who  have 
had  wide  experience  at  the  bedside  and  in  the  clinical  laboratory. 

The  Medical  Record 

"  The  association  in  its  authorship  of  a  celebrated  clinician  and  a  well-known  laboratory 
worker  is  most  fortunate.     It  must  long  occupy  a  pre-eminent  position." 


THE  PRACTICE   OF  MEDICINE 


Anders* 
Practice   of  Medicine 


A  Text=Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.  D.,  Ph.  D.,  LL,  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  Hand- 
some octavo,  1336  pages,  fully  illustrated.  Cloth,  $^.^0  net;  Half 
Morocco,  ^7.00  net. 

THE  NEW  (I2th)  EDITION 

The  success  of  this  work  is  no  doubt  due  to  the  extensive  consideration  given 
to  Diagnosis  and  Treatment,  under  Differential  Diagnosis  the  points  of  distinction 
of  simulating  diseases  being  presented  in  tabular  form.  In  this  new  edition 
Dr.  Anders  has  included  all  the  most  important  advances  in  medicine,  keeping 
the  book  within  bounds  by  a  judicious  elimination  of  obsolete  matter.  A  great 
many  articles  have  also  been  rewritten. 

Wm.  E.  Quine,  M.  D., 

Professor  of  Medicine  and  Clinical  Medicine,  College  of  Physicians  and  Surgeons,  Chicago. 
"  I  consider  Anders'  Practice  one  of  the  best  single-volume  works  before  the  profession  at 
this  time,  and  one  of  the  best  text-books  for  medical  students." 


DaCosta's  Physical  Diag(nosis 

Physical  Diagnosis.  By  John  C.  DaCosta,  Jr.,  M.  D.,  Associate 
Professor  of  Medicine,  Jefferson  Medical  College,  Philadelphia.  Octavo 
of  589  pages,  with  243  original  illustrations.  Cloth,  $3.50  net 

NEW  (3d)  EDITION 

Dr.  DaCosta' s  work  is  a  thoroughly  new  and  original  one.  Every  method 
given  has  been  carefully  tested  and  proved  of  value  by  the  author  himself. 
Normal  physical  signs  are  explained  in  detail  in  order  to  aid  the  diagnostician  in 
determining  the  abnormal.  Both  direct  and  differential  diagnosis  are  emphasized. 
The  cardinal  methods  of  examination  are  supplemented  by  full  descriptions  of 
technic  and  the  clinical  utihty  of  certain  instrumental  means  of  research. 

Dr.  Henry  L.  Eisner,  Professor  of  Medicine  at  Syracuse  University. 

"  I  have  reviewed  this  book,  and  am  thoroughly  convinced  that  it  is  one  of  the  best  ever 
written  on  this  subject.     In  every  way  I  find  it  a  superior  production." 


.^./^.^7>/•;A'.s••  bc^oa's  ox 


Sahli*s  Diag(nostic  Methods 


A  Treatise  on  Diagnostic  Methods  of  Examination.  By  Prof. 
Dr.  H.  Saiili,  of  Bern.  Edited,  with  additions,  by  Nath'l  Bowditch 
Potter,  ]\I,  D.,  Assistant  Professor  of  Clinical  Medicine,  Columbia  Uni- 
versity (College  of  Physicians  and  Surgeons),  New  York.  Octavo  of 
1229  pages,  illustrated.     Cloth,  $6.50  net  ;   Half  Morocco,  $8.00  net. 

THE  NEW  (2d)  EDITION,  ENLARGED  AND  RESET 

Dr.  Sahli's  ^reat  work  is  a  practical  diagriosis,  written  and  edited  by  practical 
clinicians.  So  thorough  has  Ijeen  the  revision  for  this  edition  that  it  was  found 
necessary  practically  to  reset  the  entire  work.  Every  line  has  received  careful 
scrutiny,  adding  new  matter,  eliminating  the  old. 

Lewellys  F.  Bzo-ker,  M.  D. 

Professor  of  the  Principles  and  Practice  of  Medicine,  Johns  Hopkins  University 
"  I  am  delighted  with  it,  and  it  will  be  a  pleasure  to  recommend  it  to  our  students  in  the 
Johns  Hopkins  Medical  School." 

r  riedenwald  and  Ruhrah  on  Diet 

Diet  in  Health  and  Disease.  By  Julius  Friedenwald,  M.  D., 
Professor  of  Diseases  of  the  Stomach,  and  John  Ruhrah,  M.  D.,  Pro- 
fessor of  Diseases  of  Children,  College  of  Physicians  and  Surgeons, 
Baltimore.     Octavo  of  857  pages.  Cloth,  $4.00  net. 

THE  NEW  (4th)  EDITION 

This  new  edition  has  been  carefully  revised,  making  it  still  more  useful  than  the  two 
editions  previously  e.xhausted.  The  articles  on  milk  and  alcohol  have  been  rewritten,  additions 
made  to  those  on  tuberculosis,  the  salt-free  diet,  and  rectal  feeding,  and  several  tables  added, 
including  Winton's,  showing  the  composition  of  diabetic  foods. 

George  Dock,  M.  D. 

Professor  of  Theory  and  Practice  and  of  Clinical  Medicine,    Tulane   University. 
"  It  seems  to  me  that  you  have  prepared  the  most  valuable  work  of  the  kind  now  availablet 
I  am  especially  glad  to  see  the  long  list  of  analyses  of  different  kinds  of  foods." 

Carter's  Diet  Lists 

Diet  Lists  of  thr  Presbyterian  Hospital  of  New  York  City. 
Compiled,  with  notes,  by  Herbert  S.  Carter,  M.  D.  i2mo  of  129 
pages.  Cloth,  $1.00  net. 

Here  Dr.  Carter  has  compiled  all  the  diet  lists  for  the  various  diseases  and   for  conva- 
lescence as  prescribed  at  the  Presbyterian  Hospital.     Recipes  are  also  included. 


PRACTICE   OF  MEDICINE 


Kemp  on  Stomach, 
Intestines,  and  Pancreas 

Diseases  of  the  Stomach,  Intestines,  and  Pancreas.  By  Robert 
Coleman  Kemp,  M.  D.,  Professor  of  Gastro-intestinal  Diseases  at  the 
New  York  School  of  Clinical  Medicine.  Octavo  of  1021  pages,  with 
388  illustrations.     Cloth,  $6.^0  net ;   Half  Morocco,  ^8.00  net. 

NEW  (2d)  EDITION 

The  new  edition  of  Dr.  Kemp's  successful  work  appears  after  a  most  search- 
ing revision.  Several  new  subjects  have  been  introduced,  notably  chapters  on 
Colon  Bacillus  Infection  and  on  Diseases  of  the  Pancreas,  the  latter  article  being 
really  an  exhaustive  monograph,  covering  over  one  hundred  pages.  The  section 
on  Duodenal  Ulcer  has  been  entirely  rewritten.  Visceral  Displacements  are  given 
special  consideration,  in  every  case  giving  definite  indications  for  surgical  inter- 
vention when  deemed  advisable.  There  are  also  important  chapters  on  the  Intes- 
tinal Complications  of  Typhoid  Fever  and  on  Diverticulitis. 

The  Therapeutic  Gazette 

"The  therapeutic  advice  which  is  given  is  excellent.  Methods  of  physical  and  clinical 
examination  are  adequately  and  correctly  described." 


Gant  on  Diarrheas 

Diarrheal,  Inflammatory,  Obstructive,  and  Parasitic  Diseases  of 
the  Qa5tro=intestinal  Tract.  By  Samuel  G.  Gant,  M.  D.,  LL.D., 
Professor  of  Diseases  of  Sigmoid  Flexure,  Colon,  Rectum,  and  Anus, 
New  York  Post-graduate  Medical  School  and  Hospital.  Octavo  of  604 
pages,  181  illustrations.     Cloth,  $6.00  net;  Half  Morocco,  ^7.50  net. 

ILLUSTRATED 

This  new  work  is  particularly  full  on  the  two  practical  phases  of  the  subject — 
diagnosis  and  treatment.  For  instance  :  While  the  essential  diagnostic  points  are 
given  under  each  disease,  a  fuller  description  of  diagnostic  methods  is  given  in  a 
special  chapter.  The  differential  diagnosis  of  diarrheas  of  local  and  those  of  sys- 
temic disturbances  is  strongly  brought  out.  There  is  a  special  chapter  on  ner- 
vous diarrheas  and  those  originating  from  gastrogenic  and  oiterogenic  dyspepsias. 
You  get  methods  of  simultaneously  controlling  associated  constipation  and  diar- 
rhea. You  get  a  complete  formielaiy.  The  limitations  of  drugs  are  pointed  out, 
and  the  indications  and  technic  of  all  surgical  procedures  given. 

Gant  on  Constipation  and  Obstruction 

This  work  is  medical,  non-medical  (mechanical),  and  surgical,  the  latter  realty 
being  a  complete  work  on  rectocolonic  surgery. 
Octavo  of  575  pages,  with  250  illustrations.     By  Samuel  G.  Gant,  M.  D.     Cloth,  $6.00  net. 


S.ir.VD/C/^S"    BOOKS   ON 


NOTHNAGEL'S    PRACTICE 

Edited  by  ALFRED   STENGEL.  M.  D. 
Typhoid  and  Typhus  Fevers 

15y  Dk.  H.  Cursch.mann.  Edited,  with  additions,  by  William  Osler,  M.  D,, 
V.  R.  C.  r. ,  Oxford,  ]"nL;land.      Octavo  of  646  pages,  illustrated. 

Smallpox,  Varicella,  Cholera,  Erysipelas,  Pertussis,  Hay  Fever 

By  Dr.  H.  I.mmermann,  Dr.  Th.  von  Jurgensen,  Dr.  C.  Liebermeister, 
Dr.  H.  Lenhartz,  and  Dr.  G.  Sticker.  Edited,  with  additions,  by  Sir 
J.  W.  Moore,  M.  D.,  F.  R.  C.  P.  I.,  Ireland.    Octavo  of  682  pages,  illustrated. 

Diphtheria,  Measles,  Scarlet  Fever,  and  Rotheln 

V>\  William  P.  Northrui',  M.  I).,  and  Dr.  Th.  \on  Jurgensen.  Edited, 
with  additions,  by  Willia.m  P.  Northrl'I',  M.  D.,  New  York.  Octavo  of 
672  pages,  illustrated. 

Bronchi,  Pleura,  and  Inflammations  of  the  Lungs 

By  Dr.  F.  A.  Hoffmann,  Dr.  O.  Rosenbach,  and  Dr.  F.  Aufrecht. 
Edited,  with  additions,  by  John  H.  Musser,  M.  D.      Octavo  of  1029  pages. 

Pancreas,  Suprarenals,  and  Liver 

By  Dr.  L.  Oser,  Dr.  E.  Neusser,  and  Drs.  H.  Quincke  and  G.  Hoppe- 
Seyler.  Edited,  with  additions,  by  Reginald  H.  Fitz,  M.  D.,  Boston; 
and  Fred.  A.  Packard,  M.  D.,  Phila.     Octavo  of  918  pages,  illustrated. 

Diseases  of  the  Stomach 

By  Dr.  F.  Riegel,  of  Giessen.  Edited,  with  additions,  by  Charles  G. 
Stockton,  M.  D.  ,  Buffalo.     Octavo  of  835  pages. 

Diseases  of  the  Intestines  and  Peritoneum  Second  Edition 

By  Dr.  Hermann  Nothnagel.  Edited,  with  additions,  by  H.  D.  Rolles- 
TON,  M.  D.,  F.  R.  C.  p.,  London.      Octavo  of  1 100  pages,  illustrated. 

Tuberculosis  and  Acute  General  Miliary  Tuberculosis 

By  Dr.  G.  Cornet.  Edited,  with  additions,  by  Walter  B.  James,  M.D., 
New  York.     Octavo  of  806  pages. 

Diseases  of  the  Blood 

By  Dr.  P.  Ehrlich,  Dr.  A.  Lazarus,  Dr.  K.  von  Noorden,  and  Dr. 
Felix  Pinkus.  Edited,  with  additions,  by  Alfred  Stengel,  M.  D.,  Phila- 
delphia.    Octavo  of  714  pages,  illustrated. 

Malarial  Diseases,  Influenza,  and  Dengue 

By  Dr.  J.  Mannaberg  and  Dr.  O.  Leichtenstern.  Edited,  with  additions, 
by  Ronald  Ross,  F.  R.  C.  S,;  J.  W.  W.  Stephens,  M.  D.;  and  Albert 
S.  Grunbaum,  F.  R.  C.  p.  ,  Liverpool.      Octavo  of  769  pages,  illustrated. 

Kidneys,  Spleen,  and  Hemorrhagic  Diatheses 

By  Dr.  H.  Senator  and  Dr.  j\I.  Litten.  Edited,  with  additions,  by  James 
B.  Herrick,  M.  D.,  Chicago.     Octavo  of  815  pages,  illustrated. 

Diseases  of  the  Heart 

By  Prof.  Dr.  Th.  von  Jurgensen,  Prof.  Dr.  L.  Krehl,  and  Prof.  Dr. 
L.  von  Schrotter.  Edited  by  George  Dock,  M.  D.,  New  Orleans.  Octavo 
of  848  pages,  illustrated. 

SOLD  SEPARATELV-PER    VOLUME:    CLOTH.  $5.00  NET;    HALF  MOROCCO,  $6.00   NET 


THERAPEUTICS  ANJ)    EXERCISE 


Bastedo's   Materia   Medica 

Pharmacoloj(y,    Therapeutics,    Prescription     Writing 

Materia  Medica,  Pharmacology,  Therapeutics,  and  Prescription 
Writing.  By  W.  A.  Bastedo,  Ph.  D.,  M.  D.,  Associate  in  Pharma- 
cology and  Therapeutics  at  Columbia  University,  New  York.  Octavo 
of  602  pages,  illustrated.  Cloth,  ;$3.50  net. 

THREE  PRINTINGS  IN  SIX  MONTHS 

Dr.  Bastedo's  discussion  of  his  subject  is  very  complete.  As  an  illustration, 
take  the  pharmacologic  action  of  the  drug.  It  gives  you  the  antiseptic  action,  the 
local  action  on  the  skin,  mucous  membranes,  and  the  alimentary  tract  ;  where  the 
drug  is  obsorbed,  if  at  all — and  how  rapidly.  It  gives  you  the  systemic  action  on  the 
circulatory  organs,  respiratory  organs,  nervous  system,  and  sense  organs.  It  tells 
you  how  the  drug  is  changed  in  the  body.  It  gives  you  the  route  of  elimination 
and  in  what  form.  It  gives  you  the  action  on  the  kidneys,  bladder,  urethra,  skin, 
bowels,  lungs,  and  mammary  glands  during  ehmination.  It  gives  you  the  after- 
effects. It  gives  you  the  unexpected — the  unusual — effects.  It  gives  you  the 
tolerance — habit  formation.  Could  any  discussion  be  more  complete,  more 
thorough  ? 

Boston  Medical  and  Surgical  Journal 

"  Its  aim  throughout  is  therapeutic  and  practical,  rather  than  theoretic  and  pharmacologic. 
The  text  is  illustrated  with  sixty  well-chosen  plates  and  cuts.  It  should  prove  a  useful  con- 
tribution to  the  text-book  literature  on  these  subjects." 


McKenzie  on  Exercise  in 
Education    and    Medicine 

Exercise  in  Education  and  Medicine.  By  R.  Tait  McKenzie,  B.  A.^ 
M.  D.,  Professor  of  Physical  Education  and  Director  of  the  Department, 
University  of  Pennsylvania.  Octavo  of  585  pages,  with  478  original 
illustrations.  Cloth,  ;^4.oo  net. 

D.  A.  Sargeant,   M.   D.,  Director  of  Hemenway  Gymnasium,  Harvard  Uni'^ersity. 

"  It  cannot  fail  to  be  helpful  to  practitioners  in  medicine.  The  classification  of  athletic 
games  and  exercises  in  tabular  form  for  different  ages,  sexes,  and  occupations  is  the  work  of  an 
expert.     It  should  be  in  the  hands  of  every  physical  educator  and  medical  practitioner." 

Bonney's  Tuberculosis  second  Edition 

Tuberculosis.     By  Sherman  G.  Bonney,  M.  D.,  Professor  of  Medi- 
cine, Denver  and  Gross  College  of  Medicine.     Octavo  of  955  pages,  with 
243  illustrations.      Cloth,  I7. 00  net ;   Half  Morocco,  ;^8. 50  net. 
Maryland  Medical  Journal 

"  Dr.  Bonney's  book  is  one  of  the  best  and  most  exact  works  on  tuberculosis,  in  all  its 
aspects,  that  has  yet  been  published." 


12  SAUXI)£/^S'    BOOK'S   ON 

Stevens'  Therapeutics  New  (sth)  Edition 

A  Text-Book,  of  Modern  Materia  Medica  and  Therapeutics. 
By  A.  A.  Stevens,  A.  M.,  M.  D.,  Lecturer  on  Physical  Diagnosis  in 
the  University  of  Pennsylvania.    Octavo  of  675  pages.     Cloth,  J3. 50  net. 

Dr.  Stevens'  Therapeutics  is  one  of  the  most  successful  works  on  the 
subject  ever  published.  In  this  new  edition  the  work  has  undergone  a 
very  thorough  revision,  and  now  represents  the  very  latest  advances. 

The  Medical  Record,  New  York 

"  .Among  the  numerous  treatises  on  this  most  important  branch  of  medical  practice, 
this  by  Dr.  Stevens  has  ranked  with  the  best." 

Btrtler*s  Materia  Medica  New  (6th)  Edition 

A  Text-Book  of  Materia  Medica,  Therapeutics,  and  Pharma- 
cology. By  George  F.  Butler,  Ph.  G.,  M.  D.,  Professor  and  Head 
of  the  Department  of  Therapeutics  and  Professor  of  Preventi\e  and 
Clinical  Medicins,  Chicago  College  of  Medicine  and  Surgery,  Medical 
Department  Valpariso  University.  Octavo  of  702  pages,  illustrated. 
Cloth,  S4.00  net;  Half  Morocco,  $5.50  net. 

For  this  sixth  edition  Dr.  Butler  has  entirely  remodeled  his  work,  a  great 
part  having  been  rewritten.  All  obsolete  matter  has  been  eliminated,  and 
special  attention  has  been  given  to  the  to.xicologic  and  therapeutic  effects 
of  the  newer  compounds. 

Medical  Record,  New  York 

"  Nothing  has  been  omitted  by  the  author  which,  in  his  judgment,  would  add  to  the 
completeness  of  the  te.xt." 

Sollmann*s  Pharmacologjy  New  (2d)  Edition 

A  Text-Book  of  Pharmacology.  By  Torald  Sollmann,  M.  D., 
Professor  of  Pharmacology  and  Materia  Medica,  Western  Reserve  Uni- 
versity.    Octavo  of  1070  pages,  illustrated.     Cloth,  $4.00  net. 

The  author  bases  the  study  of  therapeutics  on  systematic  knowledge  of 
the  nature  and  properties  of  drugs,  and  thus  brings  out  forcibly  the  intimate 
relation  between  pharmacology  and  practical  medicine. 

Slade's  Physical  Examination  and  Diagnostic  Anatomy 

Physical  Examination  and  Diagnostic  Anatomy.  By  Charles  B. 
Slade,  M.  D.,  Chief  of  Clinic  in  General  Medicine,  University  and 
Bellevue  Hospital   Medical   College.     Cloth,  $1.25  net. 

"  The  fundamental  methods  and  principles  of  physical  examination,  well  illustrated,  largely  by  line 
drawings.     The  book  is  to  be  strongly  recommended." — Boston  Medical  and  Surreal  Journal. 

Arny*s  Pharmacy 

Principles  of  Pharmacy.  By  Henry  V.  Arny,  Ph.  G.,  Ph.  D., 
Professor  of  Chemistry,  New  York  College  of  Pharmacy.  Octavo  of 
1 1 75  pages,  with  246  illustrations.      Cloth,  $5.00  net. 


THERAPEUTICS  AND   MATERIA    MEDICA  13 

Tousey's  Medical  Electricity 
Ront^en  Rays,  &nd  Radium 

Medical  Electricity,  Rontgen  Rays,  and  Radium.  \\y  Sinclair 
TousEY,  M.  D.,  Consulting  Surgeon  to  St.  Bartholomew's  Hospital, 
New  York.  Octavo  of  1219  pages,  with  801  illustrations,  iq  in  colors. 
Cloth,  I7.50  net;   Half  Morocco,  ^9.00  net. 

NEW  (2d)  EDITION,  RESET 

The  revision  for  this  edition  was  extremely  heavy  ;  new  matter  has  increased  the  size 
of  the  book  by  some  loo  pages.  About  50  new  illustrations  .have  been  added.  'Ihe  new 
matter  added  includes :  Diathermy,  sinusoidal  currents,  radiography  with  intensifying 
screens,  rontgenotherapy,  the  Coolidge  and  similar  Rontgen  tubes  and  the  author's  method 
of  dosage,  and  radium  therapy  are  noted.  The  book  has  been  enriched  by  including  several 
of  Machado's  tabular  classifications  of  electric  methods,  effects,  and  uses. 

Throughout  the  entire  work  everything  concerning  electricity,  x-rays,  and  radium  in 
medicine,  as  well  as  phototherapy,  is  explained  in  detail — nothing  is  omitted.  It  tells  you 
how  to  equip  your  office,  and,  more  than  that,  how  to  use  your  apparatus,  explaining  away 
all  difficulties.  It  tells  you  just  how  to  apply  these  measures  in  the  treatment  of  disease. 
The  chapters  on  dental  radiography  are  particularly  valuable  to  those  interested  in  dental 
work. 


Deaderick  &  Thompson's  Endemic 
Diseases  of  South 

Endemic  Diseases  of  the  Southern  States.  By  William  H. 
Deaderick,  M.  D.,  Member  American  Society  of  Tropical  Medicine  ; 
and  LoYD  Thompson,  M.  D.,  Charter  Member  American  Association 
of  Immunologists.  Octavo  of  546  pages,  illustrated.  Cloth,  ^5.00 
net;   Half  Morocco,  ^6.50  net. 

JUST  ISSUED 

This  work  records  the  experiences  of  two  active  practitioners  and  teachers 
right  in  the  field  and  thoroughly  familiar  with  these  diseases.  Those  diseases  of 
special  importance  are  given  unusual  consideration.  Pellagra,  for  instance,  is 
given  eight  chapters  for  its  full  consideration,  while  hookworm  disease  covers  nine 
chapters  and  malaria  eight.  You  get  the  etiology,  pathology,  clinical  histor)-, 
diagnosis,  prognosis,  prophylaxis,  and  treatment  of  each  disease,  presented  from 
every  angle,  always  bearing  in  mind  the  practical  aim  of  the  work — the  applicatio7i 
of  the  knowledge  in  daily  practice. 


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THE  BEST  i\  111  6  1  1  C  Ci  11  STANDARD 

Illustrated    Dictionary 


New  (8th)  Edition— 1500  New  Words 

The  American  Illustrated  Medical  Dictionary By  W.  A.  New- 
man Borland,  M.  D.,  Editor  of  "The  American  Pocket  Medical  Dic- 
tionar}'."  Large  octavo  of  1 137  pages,  bound  in  full  flexible  leather. 
Price,  54.50  net;  with  thumb  index,  $5.00  net. 

KEY  TO  CAPITALIZATION  AND  PRONUNCIATION— ALL  THE  NEW  WORDS 

Howzkrd  Au  l^eWyt^l.T),,  Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University. 

"  Dr.  Borland's  dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it." 


Thornton's  Dose-Book.  New  (4th)  Edition 

Dose-Book  and  Manual  of  Prescription-Writing.  By  E.  Q.  Thornton,  M.D., 
Assistant  Professor  of  Materia  Medica,  Jefferson  Medical  College,  Philadelphia.  Post- 
octavo,  410  pages,  illustrated.     Flexible  leathei-,  ^2.00  net. 

"  I  will  be  able  to  make  considerable  use  of  that  part  of  its  contents  relating  to  the  correct 
terminology  as  used  in  prescription-writing,  and  it  will  afford  me  much  pleasure  to  recom- 
mend the  book  to  my  classes,  who  often  fail  to  find  this  information  in  their  other  text- 
books."— C.  H.  Miller,  M..!).,  Professor  of  Pharmacology ,  Norikwestern  University  Medi- 
cal School. 

Lusk    on    Nutrition  New  (2d)  Edition 

Elements  of  the  Science  of  Nutrition.  By  Graham  Lusk,  Ph.  D.,  Professor 
of  Physiology  in  Cornell  University  Medical  School.  Octavo  of  402  pages.  Cloth,. 
33.00  net. 

"  I  shall  recommend  it  highly.  It  is  a  comfort  to  have  such  a  discussion  of  the  subject." 
—  Lewellys  F.  Barker,  M.  D.,  Johns  Hopkins  University. 

Camac*s  "Epoch-making  Contributions" 

Epoch-making  Contributions  in  Medicine  and  Surgery.  Collected  and 
arranged  hy  C.  N.  B.  Camac,  M.  D.,  of  New  York  City.  Octavo  of  450  pages,  illus- 
trated.    Artistically  bound,  $4.00  net. 

"  Dr.  Camac  has  provided  us  with  a  most  interesting  aggregation  of  classical  essays^ 
We  hope  that  members  of  the  profession  will  show  their  appreciation  of  his  endeavors."— 
Therapeutic  Gazette. 


PRACTICE,    MATERIA   MEDICA,    Etc.  15 

The  American  Pocket  Medical  Dictionary  New  (pthj  Edition 

The  American  Pocket  Medical  Dictionaky.  Jviiied  by  W.  A.  Newma-n  Dor- 
land,  M.  D.,  Editor  "American  Illustrated  Medical  Dictionary."  693  pages.  Flexible 
leather,  with  gold  edges,  ^i.oo  net;   with  thumb  index,  Ji5i.25  net. 

Pusey  and  Caldwell  on  X-Rays  Second  EdiUon 

The  Practical  Application  of  the  Rontgen  Rays  in  Therapeutics  and 
DiAc.Nosis.  By  William  Allen  Pusey,  A.  M.,  M.  D.,  Professor  of  Dermatology  in 
the  University  of  Illinois;  and  Eugene  W.  Caldwell,  B.  S.,  PJirector  of  the  Edward 
N.  Gibbs  X-Ray  Memorial  Laboratory  of  the  University  and  Bellevue  Hospital  Medical 
College,  New  York.  Octavo  of  625  pages,  with  200  illustrations.  Cloth,  #5.00  net; 
Half  Morocco,  ;^6.5o  net. 

Cohen    and    Eshner's    Diagnosis.      Second  Revised  Edition 

Essentials  of  Diagnosis.  By  S.  Solis-Cohen,  M.  D.,  Senior  Assistant  Professor 
in  Clinical  Medicine,  Jefferson  Medical  College,  Phila.  ;  and  A.  A.  Eshnior,  M.  D., 
Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  Post-octavo,  382  pages  ;  55 
illustrations.      Cloth,  ^l. 00  net.     In  Saunders'  Question- Compend  Series. 

Morris*  Materia  Medica  and  Therapeutics.  New  (7th)  Edition 

Essentials  of  Materia  Medica,  Therapeutics,  and  PREscRiPTioN-WRniNG. 
By  Henry  Morris,  M.  D.,  late  Demonstrator  of  Therapeutics,  Jefferson  Medical 
College,  Phila.  Revised  by  W.  A.  Bastedo,  M.  D.,  Instructor  in  Materia  Medica  and 
Pharmacology  at  Columbia  University.  1 2mo,  300  pages.  Cloth,  ^l.oo  net.  In  Saunder'^ 
Question-  Compend  Series. 

Kelly's  Cyclopedia  of  American  Medical  Biography 

Cyclopedia  of  American  Medical  Biography.  By  Howard  A.  Kelly,  M.  D., 
Johns  Hopkins  University.  Two  octavos  of  525  pages  each,  with  portraits.  Per  set: 
Cloth,  ^10.00  net ;    Half  Morocco,  ^13.00  net. 

Todd's  Clinical  Diagnosis  The  New  {3d)  Edition 

A  Manual  of  Clinical  Diagnosis.  By  James  Campbell  Todd,  M.D.,  Professor 
of  Pathology,  University  of  Colorado.  l2mo  of  585  pages,  with  164  text-illustrations 
and  10  colored  plates.     Cloth,  ^2.50  net. 

Bridge  on  Tuberculosis 

Tuberculosis.  By  Norman  Bridge,  A.  M.,  M.  D.,  Emeritus  Professor  of  Medicine 
in  Rush  Medical  College.     i2mo  of  302  pages,  illustrated.    Cloth,  ^1.50  net. 

Oertel  on  Bright' s  Disease  illustrated 

The  Anatomic  Histological  Processes  of  Bright's  Disease.  By  Horst 
Oertel,  M.  D.,  Director  of  the  Russell  Sage  Institute  of  Pathology,  New  York.  Octavo 
of  227  pages,  with  44  text-cuts  and  6  colored  plates.     Cloth,  $5.00  net. 

Arnold's  Medical  Diet  Charts 

Medical  Diet  Charts.  Prepared  by  H.  D.  Arnold,  M.  D.,  Dean  of  Harvard 
Graduate  Medical  School,  Boston.  Single  charts,  5  cents;  50  charts,  ^2. GO  net ;  500 
charts,  ^18.00  net;   1000  charts,  I30.00  net. 

Eggleston's  Prescription  Writing 

Essentials  of  Prescription  Writing.  By  Gary  Eggleston,  M.  D.,  Instructor 
in  Pharmacology,  Cornell  University  Medical  School.  i6mo  of  125  pages.  Cloth,  $1.00 
net. 


1 6  SAUNDERS'    BOOKS   OX  PRACTICE,  Etc. 

Jakob  and  Eshner's  Internal  Medicine  and  Diagnosis 

Atlas  AND  Epitome  of  Internal  Mkdicine  and  Clinical  Diagnosis.  By  Dr. 
Chk.  Jakok,  of  Erlangen.  Edited,  with  additions,  by  A.  A.  Eshner,  M.  1).,  Pro- 
fessor of  Clinical  Medicine,  riiiladclpliia  Tolyclinic.  With  1S2  colored  figures  on 
68  plates,  64  text-illustrations,  259  pages  of  texL  Cloth,  $3.00  net.  ///  Saumiers' 
Hand-Atlas  Series. 

Abbott's  Medical  Electricity 

MiDicAi.  Ij.KciKui  lY.  r>y  ('.iiiRc.E  Knapp  Arbott,  M.  D.,  Dean  and  Pro- 
fessor of  rhysiologir  Therapy  and  Practice.  Colle:j;c  of  Medical  Evangelists,  Loma  Linda, 
California.      i2nio  of  132  pages,  illustrated.     Cloth,  $1.25  net. 

Stevens'  Practice   of   Medicine  New  (loth)  Edition 

A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Stevens,  A.  M.,  M.  D., 
Professor  of  Pathology,  Woman's  Medical  College,  I'hila.  Specially  intended  for 
students  preparing  for  graduation  anil  hospital  examinations.  Post-octavo,  629  pages, 
illustrated.      Flexible  leatlier,  S2.50   net. 

Saunders*  Pocket  Formulary  New  (9th)  Edition 

Sai'Nders'  Pocket  Medical  Formulary.  By  William  M.  Powell,  M.  D. 
Containing  1S31  formulas  from  the  best-known  authorities.  W'ilh  an  Appendix  con- 
taining Posologic  Table,  Formulas  and  Doses  for  Hypodermic  Medication,  Poisons  and 
their  Antidotes,  Diameters  of  the  Female  Pelvis  and  Fetal  Head,  Obstetrical  Table, 
Diet-list,  Materials  and  Drugs  used  in  Antiseptic  Surgery,  Treatment  of  Asphyxia  from 
Drowning,  Surgical  Remembrancer.  Tables  of  Incompatibles,  Eruptive  Fevers,  etc., 
etc.     In  flexible  leather,  with  side  index,  wallet,  and  Hap,  $1.75  net. 

De&derick  on  Malaria 

l'K.\cricAL  Study  of  Malaria.  By  \Villiam  H.  Deaderuk,  M.  D.,  Member 
American  Society  of  Tro]iical  Medicine;  Fellow  Londnn  Society  of  Tropical  Medicine 
and  Hygiene.  Octavo  of  402  pages,  illustrated.  Cloth,  ^4.50  net;  Half  Morocco, 
$6.00  net. 

NileS    on    Pellagra  New  (2d)   Edition 

Phi.lagka.        Bv     (Jeorge    M.    Nilis,    M.  D.,    Gastroentei'ologi.st   to  the  Georgia 
Baptist  Hospital,  Atlanta.     Octavo  of  225  pages,  illustrated.      Cloth,  $3.00  net. 

Hinsdale's  Hydrotherapy 

Hydrotherapy.  By  Guy  Hinsdale,  M.  D.,  Fellow  Royal  Society  of  Medicine 
of  Great  Britain.      Octavo  of  466  pages,  illustrated.      Cloth,  $3.50  net. 

Swan's  Prescription-writing  and  Formulary 

Prescription-writing  and  Formulary.  By  John  M.  Swan,  M.  D.,  formerly 
Director  Glen  Springs  Sanitarium,  Watkins,  N.  Y.  i6mo  of  185  pages.  Flexible 
leather,  $1.25  net. 

Stewart's  Pocket  Therapeutics  and  Dose-book      |^tSn 

Pocket  Therapeutics  and  Dose-Book.  By  Morse  Stewart,  Jr.,  M.  D.  samo 
of  263  pages.     Cloth,  ^i.oo  net. 


[1  5  1949 

J 


